Student Survey for Grades 3-8


A red asterisk (*) indicates required questions.

  1. During the day yesterday, how many times did you eat fruit OR drink fruit juice? (add together)*
    0
    1
    2
    3
    4
    5
    6 or more


  1. During the day yesterday, how many times did you eat vegetables OR drink vegetable juice? (add together)*
    0
    1
    2
    3
    4
    5
    6 or more


  1. During the day yesterday, how many times did you drink milk OR eat cheese OR have yogurt? (add together)*
    0
    1
    2
    3
    4
    5
    6 or more


  1. When you eat at home, what do you normally drink with meals? *
    MILK
    WATER
    JUICE
    POP/SODA
    OTHER


  1. During a normal week, how many meals do you eat at “fast food” restaurants such as McDonald’s, Culvers, Taco Bell, Hardees, Pizza Hut, KFC, etc.*
    0
    1
    2
    3
    4
    5
    6 or more


  1. How many cans, bottles, glasses of soda/pop do you drink during a normal week?*
    0 to 3
    4 to 7
    8 to 11
    12 or more


  1. How often do you normally sit down with the entire family (those living at home with you) for meals in a typical week? *
    NEVER
    SOMETIMES
    USUALLY
    ALWAYS


  1. How many home cooked meals do you eat during a normal day that was prepared by an adult? *
    0
    1
    2
    3
    4
    5
    6 or more


  1. During a normal week, how many hours do you watch TV?*
    0 to 3
    4 to 7
    8 to 11
    12 to 15
    16 or more


  1. During a normal week, how many hours do you spend at home on the computer OR playing some type of video game? (add together)*
    0 to 3
    4 to 7
    8 to 11
    12 to 15
    16 or more


  1. During a normal week, how often does your family exercise together (such as biking, roller blading, or walking)?*
    NEVER
    SOMETIMES
    USUALLY
    ALWAYS


  1. During a normal week, how many times do you exercise or play hard for at least 20 minutes so that you sweat and breathe hard? *
    0
    1
    2
    3
    4
    5
    6 or more


  1. Have you ever used WiiFit, Dance, Dance Revolution or some other type of exer-gaming activity to get a workout?*
    YES
    NO


  1. Would you prefer participating an individual sports (badminton, exer-gaming, WiiFit, biking, etc.) physical education class rather than competing in team sports (soccer, football, basketball, softball, etc.) physical education class? *
    INDIVIDUAL SPORTS
    TEAM SPORTS





Mr. Brogley
Black Creek Middle School
WI