Shape Up Somerville – Family Survey Form
Page 1 of 9
Friedman School of Nutrition Science and Policy, Tufts University
FAMILY SURVEY FORM
Dear parents/guardians,
The following questions contain very important information about your child’s medical history,
dietary habit and physical activities.
•
•
•
Please check the boxes with a “3” or “2” and fill in the necessary information
Place a question mark (?) beside any item that you do not understand
Write NA (not applicable) beside any item that does not apply to your child
This form will take 15 minutes to complete
All information that is reported on this form is confidential and used only for research purposes.
We would understand, because of any personal reason, you do not want to answer certain
questions. Please just write down “Don’t want to answer” next to the question.
If you have any questions, please call (617) 636-3563 or e-mail us at [email protected]
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 2 of 9
Today’s date:
_____ / _____ / 2003
Child’s name:
(First)
(Last)
Your name:
(First)
(Last)
Relationship to child:
(month / day / year)
Mother
Father
Female guardian (e.g. grandmother, aunt or others):
_________________________________________
Male guardian (e.g. grandfather, uncle of others):
_________________________________________
FAMILY INFORMATION
1. What is your marital status? (Check one below)
Never married
Married
Separated/Divorced
Widowed
2. Which age category are you in? (Check one below)
18 – 24
25 – 29
30 – 39
40 – 49
50 – 59
60 or older
3. How many adults over the age of 18 live with you?
___________________
4. How many brothers and sisters does your child have?
Brothers : __________
Sisters
: __________
5. Was your child’s mother born in the United States?
Yes
No
If NO, in what country? _______________________________,
and how long has your child’s mother lived in the United States? ______ years ______ months
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 3 of 9
6. Was your child’s father born in the United States?
Yes
No
If NO, in what country? _______________________________,
and how long has your child’s father lived in the United States? ______ years ______ months
7. What is the highest level of education finished by your child’s mother? (Check one below)
Less than high school, last grade completed was _______________________
High school
GED
Trade school
College (2-year)
College
Graduate school
Don’t know
8. What is the highest level of education finished by your child’s father? (Check one below)
Less than high school, last grade completed was _______________________
High school
GED
Trade school
College (2-year)
College
Graduate school
Don’t know
9. Is there an adult in your household who is a smoker?
Yes
No
11. What is your child’s mother’s weight?
________ pounds
Don’t know
12. What is your child’s mother’s height?
________ feet ________ inch
Don’t know
13. What is your child’s father’s weight?
________ pounds
Don’t know
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 4 of 9
14. What is your child’s father’s height?
________ feet ________ inch
Don’t know
15. Is your child adopted?
Yes
No
Don’t know
CHILD MEDICAL INFORMATION
1. Has your child had a medical check-up within the previous 12 months (Sep 2002 to Aug 2003)?
Yes
No
Don’t know
2. Has your child’s doctor ever told you that your child is overweight?
Yes
No
Don’t know
3. Does your child have any of the following health conditions? (Check all that apply)
Hearing loss………………….
Visual impairment…………...
Asthma……………………….
Congenital heart failure…….
Seizures……………………...
Sickle cell anemia…………...
Bone or joint pain/injury…….
Developmental disabilities or
special needs……………..
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Other, please describe:________________________________________________________
4. Are there any reasons why your child should not participate in physical activities?
If so, please describe.
___________________________________________________________________________
___________________________________________________________________________
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 5 of 9
CHILD EATING HABITS
1. How many servings of fruits (1 serving is about the size of a medium apple or 1 cup of melon
cubes) does your child eat during a typical day? (Check one below)
0
1
2
3
4
5 or more
2. How many servings of vegetables (1 serving is about a cup of leafy vegetable or half a cup of
cooked vegetable like carrot/potato) does your child eat during a typical day?
(Check one below)
0
1
2
3
4
5 or more
3. How many servings of dairy products (1 serving is a cup of milk or yogurt, or a slice of cheese)
does your child eat during a typical day? (Check one below)
0
1
2
3
4
5 or more
4. How many times in a typical school day does your child have snack?
________ times
5. What three snack foods does your child eat the most?
_______________________, _______________________, _______________________
None, my child does not eat snack
Don’t know
6. How many servings of beans (1 serving is half a cup of baked beans, cooled kidney beans, or
black beans) does your child eat during a typical WEEK? (Check one below)
0
1 to 2
3 to 4
5 to 6
7 or more
Don’t know
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 6 of 9
7. Does your child drink any sodas (e.g. Mountain Dew, Coca Cola, Pepsi)?
1 can = 12 oz.; 1 liter bottle = 3 cans
No
Yes, about _______ cans a day OR about _______ cans a week
Don’t know
8. Does your child drink any other sugar sweetened beverages (e.g. Hi-C, Kool-aid, Sport
Drinks)?
1 can = 12 oz.; 1 liter bottle = 3 cans
No
Yes, about _______ cans a day OR about _______ cans a week
Don’t know
9. During the school week, where do most of your child’s breakfasts come from?
(Check one below)
Home
School
Restaurant
Doesn’t have breakfast
Other
Don’t know
10. During the school week, where do most of your child’s lunches come from?
(Check one below)
Home
School
Restaurant
Other
Don’t know
11. During the school week, where do most of your child’s dinners come from?
(Check one below)
Home
Restaurant
Other
Don’t know
12. During the school week, where do most of your child’s snack foods come from?
(Check one below)
Home
Store
School
Restaurant
Other
Doesn’t have snack
Don’t know
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 7 of 9
13. Does your child have food allergies?
Yes
No
Don’t know
If yes, to what foods?___________________________________________________________
14. Does your child take any multi-vitamin and mineral supplement?
Yes
No
Don’t know
If yes, how often?
Daily
Occasionally
Rarely
CHILD TV WATCHING
1. On a typical school day, how much time does your child spend:
a. Watching TV……………………………….
__________ hours and __________ minutes
b. Watching videos or DVDs……………….
__________ hours and __________ minutes
c. Playing video games……………………...
__________ hours and __________ minutes
d. On the computer…………………………..
__________ hours and __________ minutes
2. On a typical weekend day, how many hours does your child spend on:
a. Watching TV……………………………….
__________ hours and __________ minutes
b. Watching videos or DVDs……………….
__________ hours and __________ minutes
c. Playing video games……………………...
__________ hours and __________ minutes
d. On the computer…………………………..
__________ hours and __________ minutes
3. How often does your child eat breakfast in a room with the TV turned on?
A lot
Sometimes
Not very much
Never
Don’t know
Ver. 1.0
Shape Up Somerville – Family Survey Form
Page 8 of 9
4. How often does your child eat dinner in a room with the TV turned on?
A lot
Sometimes
Not very much
Never
Don’t know
5. Is there a TV in the room where your child sleeps?
Yes
No
Don’t know
CHILD PHYSICAL ACTIVITIES
1. Please list the organized sports and physical activities (lessons and/or teams) your child
participated in each season over the past year (for example: karate, dance, swimming, soccer,
etc.).
SUMMER:
SPRING:
WINTER:
AUTUMN:
2.In a typical school week, how many days does your child walk to school?
0
1
2
3
4
5
Don’t know
3. In a typical school week, how many days does your child walk home or to an after school
program from school?
0
1
2
3
4
5
Don’t know
OTHER INFORMATION
1. Are there rules your child has to follow…
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
about when he/she can watch television?…………………………
about how long he/she can watch television?…………………….
about going to bed at a certain time?………………………………
about drinking soda/soft drinks?……………………………………
about drinking sugar sweetened drinks?…………………………..
about eating candy or other sweets?………………………………
about snacking?………………………………………………………
about using the computer by him/herself?………………………...
about helping him/herself to food in the kitchen?….……………..
about washing hands?……………………………………………….
Ver. 1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Shape Up Somerville – Family Survey Form
Page 9 of 9
2. How often do you sit down with your child to eat dinner?
A lot
Sometimes
Not very much
Never
3. How often do you encourage your child to be physically active?
A lot
Sometimes
Not very much
Never
4. How often do you and your child do something active together, like going for a walk, playing
outside or playing sports?
A lot
Sometimes
Not very much
Never
5. How often do you and your child talk about fruits and vegetables?
A lot
Sometimes
Not very much
Never
6. Is your child part of an after school program?
Yes, my child participates in ___________________________________________________
No
Don’t know
Ver. 1.0