Questionnaire
Please answer the following questions to the best of your ability.
On a Scale of 1 to 5:
Please select the number that describes you currently:
Do you get daily physical activity?
NEVER
1
2
3
4
ALWAYS
5
1 is NEVER , 5 is ALWAYS
Do you eat healthy?
NEVER
1
2
3
4
ALWAYS
5
1 is NEVER, 5 is ALWAYS
Do you have access to food?
NEVER
1
2
3
4
ALWAYS
5
1 is NEVER, 5 is ALWAYS
Have you ever gone hungry?
ALWAYS
1
2
3
4
NEVER
5
1 is ALWAYS, 5 is NEVER
Do you get angry easily?
ALWAYS
1
2
3
4
NEVER
5
1 is ALWAYS, 5 is NEVER
Do you get in arguments a lot?
ALWAYS
1
2
3
4
NEVER
5
1 is ALWAYS, 5 is NEVER
Do you get in physical fights a lot?
ALWAYS
1
2
3
4
NEVER
5
1 is ALWAYS, 5 is NEVER
Have you ever been suspended from school?
Yes
No
Do you participate in activities outside of school?
Yes
No
Have you ever considered suicide?
Yes
No
Why do you want to participate in our program?
Submit
Should be Empty: