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5-2-1-0 Healthy Habits Questionnaires 2-9 (HE-46137)

5-2-1-0 Healthy Habits Questionnaires 2-9 (HE-46137) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


Child’s Name:
Age: Today’s Date:
1. How many servings of fruits or vegetables does your child eat a day? One
serving is about the size of the palm of your child’s hand.
2. How many times a week does your child eat dinner at the table together with
the family?
3. How many times a week does your child eat breakfast?

4. How many times a week does your child eat takeout or fast food?

5. How many hours of recreational (outside of school work) screen time does
your child get in a day?
6. Is there a television set or Internet-connected device in your child’s bedroom?
7. How many hours does your child sleep each night?

8. How many minutes a day does your child spend in active play?
(faster breathing/heart rate or sweating)
9. How many 8-ounce servings of the following does your child 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. Based on your answers, is there ONE thing you would like to help your child
change 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!
Healthy Habits Questionnaire
Ages 2-9
HE-46137-16
5210
This handout is adapted
from Let’s Go! materials.
www.letsgo.org.uwhealth.org/go5210