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Pre- and Post Test
Pre and Post-Test
Student Initial / Subsequent Screening Tool
(Pre-Test and Post-Test)
Student Name
*
First
Last
School
*
Screening Date
*
Date Format: MM slash DD slash YYYY
Is this the pre-test or post-test?
*
Pre-Test
Post-Test
Gender Identity
*
Male
Female
Birth Date
*
Date Format: MM slash DD slash YYYY
Age
*
Height (inches)
*
Weight (pounds)
*
What do you drink when you are feeling thirsty? (pres the Ctrl button to choose multiple answers)
*
Water
Milk (including soy)
Sports Drink
Soft Drink / Soda
Fruit Juice
Coffee / Tea
How many 8 oz. cups of water do you drink per day?
*
0
1
2
3
4
5
6
7
8+
How many 8 oz. cups of sweetened beverages (sports drinks, fruit juice, soft drinks) do you drink per day?
*
0
1
2
3
4
5
6
7
8+
How many servings of calcium (milk, cheese, fortified soy milk) do you have per week?
*
0
1
2
3
4
5
6
7
8+
How many servings of fruits do you have per week?
*
0
1
2
3
4
5
6
7
8+
How many servings of vegetables do you have per week?
*
0
1
2
3
4
5
6
7
8+
How many servings of grains, breads or cereal do you have per week?
*
0
1
2
3
4
5
6
7
8+
How many servings of protein do you have per week?
*
0
1
2
3
4
5
6
7
8+
How many snack foods do you eat per week?
*
0
1
2
3
4
5
6
7
8+
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?
*
0
1
2
3
4
5
6
7
8+
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?
*
0
1
2
3
4
5
6
7
8+
Including in-school and out of school activities.
How many days per week do you exercise for more than 60 minutes?
*
0
1
2
3
4
5
6
7
8+
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)
Weight Training
Running / Jogging
Walk-n-Roll
Sports
Yoga / Pilates
Exercise Videos
Other
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)
No interest
No money
Do not know how
No transportation
No time
No one to do it with
No exercise facility
Physically unable
Other
How many hours a day do you watch television or use an electronic device, such as a computer or cell phone?
*
0
1
2
3
4
5
6
7
8+
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