/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-104985-en.cckm

201712338

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

Pediatric Fitness Healthy Habit Questionnaire - Patient (NM800129)

Pediatric Fitness Healthy Habit Questionnaire - Patient (NM800129) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #



NM800129 (Rev. 11/29/17) Worksheet Only – Not a Medical Record Document, DO NOT SCAN

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PEDIATRIC FITNESS HEALTHY HABIT
QUESTIONNAIRE - PATIENT
Date: _________________________________

Please answer the following questions about your eating and physical activity habits. There are no wrong answers. By
filling out this survey honestly, you will help us to provide you with the best care possible.

1. How often do you eat in the following ways?

Eat while standing.
Never Almost never Sometimes Frequently Always

Eat straight from the bag, package, serving bowl, or pot.
Never Almost never Sometimes Frequently Always

Eat while watching television, reading, working, gaming or using an electronic device.
Never Almost never Sometimes Frequently Always

Eat when bored.
Never Almost never Sometimes Frequently Always

Eat when angry or unhappy.
Never Almost never Sometimes Frequently Always

Eat very fast.
Never Almost never Sometimes Frequently Always

2. How often do you eat in the following rooms?

Kitchen or dining room.
Never Almost never Sometimes Frequently Always

Living room or TV room.
Never Almost never Sometimes Frequently Always

Bedroom
Never Almost never Sometimes Frequently Always

3. How many times in a typical week do you eat dinner together as a family?
0 days/week 1-2 days/week 3-4 days/week 5+ days/week

4. Where do you eat breakfast?
Skips Home School Both Home & School

5. Do you bring your lunch from home, or eat hot lunch at school?
Skips Packed from Home School-provided Lunch Both Home & School

6. How many times in a typical week do you dine out (restaurants, fast food, delivery, etc.)
0 days/week 1-2 days/week 3-4 days/week 5+ days/week

7. How many servings of fruit and vegetables do you eat daily most days of the week?
(One serving is equal to 1 cup raw, ½ cup cooked, and ¼ cup dried)
0 1-2 3-4 5 5+

8. How many servings of juice, chocolate milk, soda, or sports drinks do you drink daily, most days of the week?
(One serving is equal to one cup or 8 fluid ounces)
0 1-2 3-4 5 5+

9. Do you hide or sneak food?
Yes No Not anymore

10. Do you ever find that you cannot stay full between meals and snacks?
Yes No




Patient Name

DOB:

MR #



NM800129 (Rev. 11/29/17) Worksheet Only – Not a Medical Record Document, DO NOT SCAN

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PEDIATRIC FITNESS HEALTHY HABIT
QUESTIONNAIRE - PATIENT
Food Security
11. Within the last 12 months, we [my family] worried whether our food would run out before we got money to buy
more.
Often true Sometimes true Never true

12. Within the last 12 months, the food we [my family] bought just didn’t last and we didn’t have money to buy
more.
Often true Sometimes true Never true

Health Perception
13. How do you perceive your own weight?
Underweight About the right weight Slightly overweight Very overweight

14. Would you say that in general your health is…?
Excellent Very good Good Fair Poor

15. How ready are you to make health-related changes?
Not ready Unsure Ready

16. How ready are you to make healthy eating changes?
Not ready Unsure Ready

17. How ready are you to make physical activity and exercise changes?
Not ready Unsure Ready

Physical Activity & Sleep
18. How many days per week do you get at least 30 minutes of physical activity?
0 1-2 3-4 5+

19. How many days per week do you get at least 60 minutes of physical activity?
0 1-2 3-4 5+

20. Who in the family exercises regularly (5 or more days per week)?
Dad Mom Sister Brother Other: _______________________

21. Do you have a TV in your bedroom?
Yes No

22. How many hours of sleep do you get most nights on SCHOOL days?
< 5 hours 6-7 hours 8-9 hours 9+ hours

23. How many hours of sleep do you get most nights on WEEKEND days?
< 5 hours 6-7 hours 8-9 hours 9+ hours

24. How much screen time (TV, movies, computer, iPod, cell phone, tablet, video games) do you have on SCHOOL
days?
< 30 minutes 30-60 minutes 1-2 hours 2-4 hours 4+ hours

25. How much screen time (TV, movies, computer, iPod, cell phone, tablet, video games) do you have on
WEEKEND days?
< 30 minutes 30-60 minutes 1-2 hours 2-4 hours 4+ hours