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Pre-Assessment Survey
Introduction:
Thank you for your participation in our effort to collect data that will ultimately assist those who want to better their overall health. This survey is designed to collect data based on influencers that affect your attitude and behavior towards eating and making food selections.
Disclaimer:
All information and results related to this survey is for informational purposes only. The information presented is not specific medical advice for any individual. The content of this survey should not substitute for medical advice from a certified health professional. If you have a health problem, speak to your doctor or a health care professional immediately about your concerns.
This survey is anonymous and confidential, so please reply to each question as honestly as possible.
DEMOGRAPHICS
*
Indicates required field
Gender
*
Male
Female
Grade Level
*
Freshman
Sophomore
Junior
Senior
Ethnicity
*
African American
African
Hispanic / Latino
Asian / Pacific Islander
White / Caucasian
Weight Range
*
100 lbs or Less
101 lbs - 134 lbs
135 lbs - 149 lbs
150 lbs - 164 lbs
165 lbs - 174 lbs
175 lbs - 184 lbs
185 lbs - 200 lbs
200 lbs - 214 lbs
215 lbs or More
Height Range
*
5’0” and Under
5’1” - 5’4”
5’5” - 5’8”
5’9” - 6’1”
6’2” - 6’4”
6’5” – 6’7”
6’8” – 7’0”
Number of People in Household
*
0 - 1
2 - 4
5-8
9-12
13 or more
QUESTIONS
There are no right or wrong answers. Your responses to the following questions will help us improve the information we provide during our class session.
1. Based on the US Government recommended healthy food plate options - consisting of fruits, vegetables, grains, and protein - How healthy is YOUR diet generally?
*
5 - Very Healthy
4 - Healthy
3 - Somewhat Healthy
2 - Unhealthy
1 - Very Unhealthy
Select One Healthy Option
2. What is the overall health status of your immediate family?
*
5 - Very Healthy
4 - Healtny
3 - Somewhat Healthy
2 - Unhealthy
1 - Very Unhealthy
3. What is your favorite meal of the day?
*
Breakfast
Lunch
Dinner
Click on dropdown to select an option.
What does your favorite meal usually include?
*
Describe what you usually eat during your favorite meal.
4. How often do you eat fast food?
*
5 - Always
4 - Often
3 - Sometimes
2 - Very Little
1 - Never
Select one option
5. What fast food restaurant do you frequent most?
*
List fast food restaurant you eat most often. Example, McDonalds, Whataburger, etc.
6. How much pressure do you feel from friends to eat fast food?
*
5 - A Lot of Pressure
4 - Often Pressure
3 - Some Pressure
4 - Very Little Pressure
1 - No Pressure
Select one option
7. What is most important to you when considering what food to buy?
*
Affordable
Good Taste
Healthy
Easy / Quick to Prepare
Select One Option
8. What grocery store does your parent(s) frequent the most?
*
9. What is most important to your family when grocery shopping?
*
Price
Quality
If Family Likes It
Low Fat
Low Salt
Organic
Food Craving at the moment
Select One
10. What grocery stores are within 2 to 3 miles of your home? If none, indicate None.
*
11. Are you a big meat eater?
*
Yes
No
Select One
If yes, what type(s) of meat do you eat?
*
Complete the following sentence by selecting the one you most agree with.
12. Eating healthy foods is …
*
Always Pleasant
Usually Pleasant
Somewhat Pleasant
Usually Unpleasant
Always Unpleasant
Select One
13. Do you think fresh produce (fruits and vegetables) is important to your health?
*
Yes
No
Select One
14. Do you like fruits and vegetables?
*
Yes
No
Select One
15. How often do you eat fresh fruits and vegetables?
*
Never
A few times a month
Once a Day
Twice a Day
3 or More Times a Day
Select One
16. Do you know the difference between Organic and Conventional Produce?
*
Yes
No
Select One
If yes, explain the difference.
*
17. Do you take vitamins?
*
Yes
No
Select One
If Yes, what vitamins do you take.
*
18. Do you exercise?
*
Yes
No
If no, why not?
*
Indicate the reason you don't exercise. (Example: no time, health issues, etc.)
19. Do your parents / grandparents suffer from high blood pressure (hypertension), cancer, diabetes, lupus, or other chronic diseases?
*
Yes
No
20. What would you like to learn about healthy eating?
*
21. What would you like to change most about your health?
*
Please click on the SUBMIT button below to complete this survey. You will receive a message if a required field was not completed. Otherwise, you will receive a confirmation message that your information was submitted.
Submit
Welcome
DHK Podcast
Testimonials
DHK WELLNESS
Store
About
COVID-2020
Contact
Resources
How To Get Started
Dish On Health
Healthy Tips
Videos
Photo Gallery
Previous Events
Recipes
Fish Tacos
Veggie Stir Fry
