| Directions: Please answer
all questions honestly. Do not put your name on this survey. A. Background Information:
1. How old are you?
12 or younger ___ 13 ___ 14___ 15___ 16___ 17___ 18 or older___
2. What is your sex?
Female ____ Male _____
3. What grade are you in?
9th____ 10th____ 11th____ 12th____
4. How do you describe yourself (select one or
more)?
American Indian or Alaskan Native____
Asian ___
Black or African American _____
Hispanic or Latino _____
Native Hawaiian or other Pacific Islander _____
White___
5. During the last 12 months, how would you describe your
grades in school?
Mostly A’s___, Mostly B’s___, Mostly C’s___,
Mostly D’s____, Mostly F’s____
6. How tall are you without your shoes on?
___ feet ____ inches
7. How much do you weigh without your shoes on?
______ pounds
B. Fruit and Vegetable Consumption
Think about all the meals and snacks you had from the time you got up until you went to
bed over the past 7 days. Be sure to include food you ate at home, at school, at
restaurants, or anywhere else.
| During the past 7 days, how
many times… |
Never |
1-3 times/week |
4-6 times/week |
1 time/day |
2 times/day |
3 times/day |
>=4 times/ day |
| Did you drink 100% fruit juices
such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports
drinks, or other fruit-flavored drinks.) |
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Did you eat fruit?
(Do not count fruit juice.) |
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| Did you eat green salad? |
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| Did you eat potatoes? |
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| Did you eat carrots? |
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| Did you eat other vegetables? (Do
not count green salad, potatoes, or carrots.) |
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C. Fruit and Vegetable Correlates
1. How strongly do you agree with the following (1 =
Strongly Disagree, 5 = Strongly Agree):
|
Strongly Disagree |
|
|
|
Strongly Agree |
| I think that I eat enough fruit most days. |
1 |
2 |
3 |
4 |
5 |
| I like the taste of most vegetables. |
1 |
2 |
3 |
4 |
5 |
| We usually have vegetables in our home. |
1 |
2 |
3 |
4 |
5 |
| If I wanted to, it would be easy for me to eat
more vegetables. |
1 |
2 |
3 |
4 |
5 |
| Fruits & vegetables are too expensive. |
1 |
2 |
3 |
4 |
5 |
| Vegetables offered at school are unappealing. |
1 |
2 |
3 |
4 |
5 |
| People who care about me think that I should eat
more fruit. |
1 |
2 |
3 |
4 |
5 |
| I intend to eat more fruit during the next month. |
1 |
2 |
3 |
4 |
5 |
| It takes too long to prepare fruits and vegetables. |
1 |
2 |
3 |
4 |
5 |
| The foods I eat affect how I look. |
1 |
2 |
3 |
4 |
5 |
| The foods I eat as a teen will affect my health
as an adult. |
1 |
2 |
3 |
4 |
5 |
| 2. Rate your preference for the
following fruit and vegetables (1 = Dislike very much, 5 = Like very much): |
|
Dislike very much |
|
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Like very much |
| Apples |
1 |
2 |
3 |
4 |
5 |
| Bananas |
1 |
2 |
3 |
4 |
5 |
| Grapes |
1 |
2 |
3 |
4 |
5 |
| Melons, Cantaloupe |
1 |
2 |
3 |
4 |
5 |
| Fruit Salad |
1 |
2 |
3 |
4 |
5 |
| Salsa and Chips |
1 |
2 |
3 |
4 |
5 |
| Dried Fruit (cranberries, raisins, apricots)
|
1 |
2 |
3 |
4 |
5 |
| Salad Bar |
1 |
2 |
3 |
4 |
5 |
| Vegetables & Dip |
1 |
2 |
3 |
4 |
5 |
| Vegetable Dishes |
1 |
2 |
3 |
4 |
5 |
|
