Pre- and Post Test

Student Name*

First Last

School*

Screening Date*

Is this the pre-test or post-test?*

Gender Identity*

Male
Female

Birth Date*

Age*

Height (inches)*

Weight (pounds)*

What do you drink when you are feeling thirsty? (pres the Ctrl button to choose multiple answers)*

How many 8 oz. cups of water do you drink per day?*

How many 8 oz. cups of sweetened beverages (sports drinks, fruit juice, soft drinks) do you drink per day?*

How many servings of calcium (milk, cheese, fortified soy milk) do you have per week?*

How many servings of fruits do you have per week?*

How many servings of vegetables do you have per week?*

How many servings of grains, breads or cereal do you have per week?*

How many servings of protein do you have per week?*

How many snack foods do you eat per week?*

Do you consume other foods or take special nutrition pills?

Vitamins, minerals or protein supplement
Nutrition Supplement Products
No

How many family meals do you have in a week?*

Family meals consist of a family sitting down together at a dinner table, passing food around, sharing and having conversation.

How many days per week do you exercise for 30-60 minutes?*

Including in-school and out of school activities.

How many days per week do you exercise for more than 60 minutes?*

Including in-school and out of school activities.

Do you exercise outside of school activities?*

Yes
No

If yes, what do you do? (pres the Ctrl button to choose multiple answers)

If you listed "other", what other forms of exercise do you participate in?

If no, what is the reason? (pres the Ctrl button to choose multiple answers)

How many hours a day do you watch television or use an electronic device, such as a computer or cell phone?*

Do you wash your hands with soap every day?*

Yes
No

If yes, how long do you wash your hands for?

0-10 seconds
11-20 seconds
21-30 seconds
More than 30 seconds

How many times per day do you brush your teeth?*

None
One
Two
Three or more

How long do you brush your teeth for?

Less than 1 minute
1-2 minutes
Over 2 minutes

Do you floss your teeth regularly?*

Yes
No

If yes, how often?

Daily
Weekly
Every two weeks
Monthly

Do you use tobacco?*

Yes
No

If yes, which products? (check all that apply)

Cigarettes
Cigars
Pipe
Chewing Tobacco

If yes (you use tobacco), how many per day?

If yes (you use tobacco), how many per week?

If yes (you use tobacco), how many per month?

If yes, have you stopped smoking for one day or longer because you were trying to quit?

Yes
No

Does anyone in your family smoke or chew tobacco?*

Yes
No

Does anyone smoke in your home or car?*

Yes
No

Student Initial / Subsequent Screening Tool