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5-2-1-0 Healthy Habits Questionnaire 10+ (HE46139)

5-2-1-0 Healthy Habits Questionnaire 10+ (HE46139) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


Your Name:
Age: Today’s Date:
1. How many servings of fruits or vegetables do you eat per day?
One serving is about the size of the palm of your child’s hand.

2. How many times a week do you eat dinner at the table together with
the family?
3. How many times a week do you eat breakfast?

4. How many times a week do you eat takeout or fast food?

5. How many hours per day do you look at a screen?

6. Is there a television set or Internet-connected device in your bedroom?

7. How many hours do you sleep each night?

8. How many minutes a day do you spend being active?
(faster breathing/heart rate or sweating)
9. How many 8-ounce servings of the following do you drink a day?
Water

Nonfat (skim), low-fat (1%) milk

Reduced-fat (2%) milk

Whole milk or chocolate milk

100% juice

Fruit or sports drink

Soda or punch

10. Is there ONE thing you would be interested in changing now?
Please check one box.
� Eat more fruits and vegetables. � Take the TV out of the bedroom.
� Eat less fast food/takeout. � Be more active – get more exercise.
� Drink less soda, juice, or punch. � Get more sleep.
� Drink more water. � Eat breakfast.
� Spend less time watching TV/movies and playing video/computer games.
� Not ready to make a change now.
11. Within the past 12 months we worried whether our food would run out before we
had money to buy more.
� Often True � Sometimes True � Never True
12. Within the past 12 months the food we bought just didn’t last, and we didn’t have
money to get more.
� Often True � Sometimes True � Never True
Please give the completed form to your clinician. Thank you!
HE-46139-16
5210
This handout is adapted
from Let’s Go! materials.
www.letsgo.org.uwhealth.org/go5210
Healthy Habits Questionnaire
Ages 10+