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3.How many meals throughout the day do you have?

one big meal

three square meals a day

five or six small meals throughout the day

eat when I can so I don’t keep count

4.How often do you dine out?

how does the stove work again

2-4 times

Only on special occasions

5-7 times

5.What are some barriers to homemade meals? Circle all that apply.

I just keep burning everything

my family is tired of my limited recipe selection

I am the chef at home

I don’t have the time

6.How frequently do you accomplish physical activity per week?

Does walking from the house to the car count

working out is my second job

five times weekly

at least three times weekly

7.Do you read labels on pre-packaged food?

I look at the picture as I enjoy my snack

I don’t eat anything that has a label attached

I make grocery decisions based on the nutrition label

I don’t know how to read those labels

9.How many servings of non-water beverages do you consume daily?

Do I have to count my four cups of coffee

My goal is eight but sometimes I don’t make it

I strive for more than half my body weight

just had a big gulp

10.How do you define good health?

Who cares we’re all gonna die anyway

no need for medication

Good, diverse diet and physical activity

Getting through another day is good enough for me

12.Which do you prefer when considering meals? Circle all that apply.

Immediate

Delicious

Nutritious

Portable

13.What is the best way to maintain a healthy weight?

Eat what I want and hope for the best

I don’t know but would like someone to help

Enjoy as many fresh fruits and vegetables as I like and find ways to stay active

I don’t think about health when shopping because it’s not in the budget

14.Which do you consider a good serving of vegetables? Circle all that apply.

I don’t like vegetables

heaping helping of smashed potatoes with lots of sour cream and cheese

a cup of broccoli

Half a bag of potato chip

18.How many times per week do you order out? Circle one

We have the pizza shop on speed dial

2-4 times

Only on special occasions

5-7 times

19.How many hours per week do you spend on family activities?

Does Facebook count

4-5 hours

7-12

Not enough

21.Describe your family’s favorite meal. (open-ended with matching boxes)

Any from take out

Homemade with no or little veggies

Homemade well-balanced meal

Frozen food section

23.How many servings per day do you consume of vegetables? Corn and potatoes not included.

I hate vegetable, you can’t make me eat them

Well, the pyramid says five fruits and vegetables, I think I might be around there

I am on a mission to get at least 7 servings a day

Maybe once or twice, we count corn and potatoes

24.What do you consider to be a regular snack for your family?

Cookies, chips, snack cakes, soda

Natural peanut butter and jelly on whole wheat bread

We like to get creative with fruits and vegetables

The occasional happy meal if they were good

25.How many hours a day do your children/ you spend on multimedia activities? (cell phones, computers, video games, television. Include work and school time)

10-16 hrs

4-5 hrs

30 min-2 hrs

6-8 hrs

26.Your child’s school employ vending machines?

True

False

31.How many hours per day do you feel are wasted?

I always lose track

4-6 hrs

2-4 hrs

6-8 hrs

33.Are you or have you ever been interested in learning more about healthier eating habits?

Yes

No

34.Are you or have you ever been interested in learning more about achieving a healthier lifestyle?

Yes

No