Healthy Living Questionnaire

Healthy Living Questionnaire
Name
Food & Drink
What Foods Do You Eat on a Typical School Day?
Breakfast:
Snack / Recess:
Lunch:
Supper:
Other Snacks:
How much water do you drink during a typical day?
How Often Do You Have These Drinks?
Juice:
Milk:
Pop/Soda:
Energy Drinks:
Tea / Coffee / Cappuccinos / Iced Caps / Etc
Physical Activity
What type of physical activities do you do?
Ex;Organized Sports/Dance, Riding Bikes. Walking, Etc
How many hours a week do you spend doing a physical activity that makes you sweat or breath a little faster than usual?
Screen Time

This includes time in front of all screens. TV, computers, laptops, tablets, phones, gaming and more
How many hours of screen time do you get on school days?
How many hours of screen time do you get on weekend days?
What device do you spend most of your screen time on?
Sleep
On school nights, what is your usual bedtime?
On school nights, what is your usual wake-up time?
On weekends, what is your usual bedtime?
On weekends, what is your usual wake-up time?
Do you have a sleep routine? If so, please describe it:
Should be Empty:

Food & Drink