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What is your height?
 
5'0-5'3
 
5'4-5'7
 
5'8-5'11
 
6'0 or over
 
 
 
What is your Gender?
 
Male
 
Female
 
 
 
What is your weight?
 
100-125
 
126-145
 
146-170
 
171-189
 
190 or more
 
 
 
How many days during the week do you eat at least one fast food meal?
 
0 days/week
 
1-3 days/week
 
4-5 days/week
 
6-7 days/week

 
 
 
How many fast food meals do you eat each week?
 
0
 
1-5
 
6-10
 
11-15
 
16 or more

 
 
 
How often do you get at least 30 minutes of physical activity?
 
0 day/week
 
1-3 days/week
 
4-5 days/week
 
6-7 days/week

 
 
 
How do you perceive your weight?
 
underweight
 
within normal limits
 
overweight
 
obese

 
 
 
the nearest fast food restaurant is how close to your home or work?
 
0-4 miles
 
5-10 miles
 
11-15 miles
 
16 or more miles

 
 
 
How many times a week do you eat a meal cooked at home?
 
0
 
1-5
 
6-10
 
11-15
 
16 ore more

 
 
 
Are/Were you parents overweight?
 
father
 
mother
 
both

 
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