Basic Information
Mandatory field First letter of your first name:*
Mandatory field First letter of your mother's first name:*
Mandatory field First letter of your last name:*
Mandatory field Birthday:*
Please select the amount that matches the 5-2-1-0 recommendations.
Mandatory field Screen time per day (TV/movies, video games, or use the cell phone or the computer for fun)*
[Please select]
5 hours or less
2 hours or less
1 hour or less
0 hours
Mandatory field Fruits and vegetables per day*
[Please select]
5 servings or more
2 servings or more
1 serving or more
0 servings
Mandatory field Sugar-sweetened beverages per day (soda, sports drinks, juice, punch, ice tea, Kool-Aid, etc.)*
[Please select]
5 servings
2 servings
1 serving
0 servings
Mandatory field Exercise or active play per day*
[Please select]
5 hours or more
2 hours or more
1 hour or more
0 hours
Progress on Goal - Complete ONLY if you have done a Healthy Living Plan before
Mandatory field The last time I filled out this survey I set a goal*
[Please select]
Yes
No
I don't remember
This is my first time completing the survey
Mandatory field If YES, thinking about last week, I accomplished my goal(s):*
[Please select]
7 days a week
5 or 6 days a week
3 or 4 days a week
1 or 2 days a week
0 days a week
Nutrition
Mandatory field How many fruits did I eat yesterday?*
[Please select]
More than 5
5
4
3
2
1
0
Mandatory field How many vegetables did I eat yesterday?*
[Please select]
More than 5
5
4
3
2
1
0
Mandatory field How many sugar-sweetened beverages (juice, soda, ice tea, Kool-Aid, sports drink) did I drink yesterday?*
[Please select]
More than 5
5
4
3
2
1
0
Mandatory field How many times did I eat junk food (cake, cookies, chips, etc.) yesterday?*
[Please select]
More than 5
5
4
3
2
1
0
Mandatory field How many times a week do I eat takeout or fast food?*
[Please select]
More than 5
5
4
3
2
1
0
Exercise and Physical Activity
Mandatory field How many days a week do I spend in active play or exercise (fast breathing, sweating)?*
[Please select]
7
6
5
4
3
2
1
0
Mandatory field On those days, how many minutes do I spend in active play or exercise (fast breathing, sweating)?*
[Please select]
60 minutes or more
45-60 minutes
30-45 minutes
15-30 minutes
15 minutes or less
Mandatory field What activities?*
Mandatory field How many hours did I watch TV/movies or sit and play video games or use the cell phone or the computer for fun yesterday?*
[Please select]
5 or more
5
4
3
2
1
0
Other Habits
Mandatory field How many times a week do I skip meals?*
[Please select]
7 or more
6-7
5-6
4-5
3-4
2-3
1
I do not skip meals
Mandatory field How many days a week do I have trouble sleeping?*
[Please select]
7
6
5
4
3
2
1
0 - I do not have trouble sleeping
Mandatory field How many times a week do I eat dinner at the table with my family?*
[Please select]
7
6
5
4
3
2
1
0 - I do not eat dinner at the table with my family
Mandatory field Do I have a TV in the room where I sleep?*
Yes No
Mandatory field 5 Increase the fruits or vegetables I eat each day to: (Check one below)*
[Please select]
5 servings or more
4 servings or more
3 servings or more
2 servings or more
1 serving or more
Mandatory field 2 Decrease screen time (TV/movies, video games, cell phones, computer etc.) to: (Check one below)*
[Please select]
2 hours
2 ½ hours
3 hours
3 ½ hours
4 hours
Mandatory field 1 Increase exercise or physical activity every day to: (Check one below)*
[Please select]
More than 1 hour
1 hour
45 minutes
30 minutes
15 minutes
Other
Mandatory field 0 Decrease sugar-sweetened drinks (soda, sports drinks, juice, punch, etc.) to: (Check one below)*
[Please select]
0 per day
1 per day
2 per day
Mandatory field Another goal:*
How confident am I to accomplish my goal?*
Mandatory field Please select your level of confidence in reaching your goal.*
[Please select]
10 - Very Confident
9
8
7
6
5
4
3
2
1
0 - Not Confident
Mandatory field What might make it hard to achieve this goal (What are my barriers)?*
First Name
Last Name
Email Address
