Teen Diet and Demographic Survey

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ATTACHMENT 4A-3: FLASHE TEENAGER DIET AND DEMOGRAPHICS SURVEY
Thank you for taking the Family Life, Activity, Sun, Health and Eating (FLASHE) Survey. This survey asks about your attitudes and opinions about the things you eat and drink, as well as other related factors. It is important that you answer the survey questions carefully and accurately, since your answers will help us understand more about why people choose to eat particular foods and drinks.
Survey Instructions

This information will help you answer the FLASHE Survey questions.

    • Some parts of the survey are about you. Others are about your parents and family. 
    • In this survey, “parent” means the adult who takes care of you. It could be your birth mother or father or your adopted mother or father. It could also be your guardian, an adult relative or an adult who isn’t related to you.
    • You’ll need about 15 minutes to do the survey. 
    • Read all the answers before marking a box.  Please mark only the box that best describes you or your family. There aren’t any right or wrong answers. 
    • Try to answer all of the questions. The more questions you answer, the more we’ll learn. If any question makes you uncomfortable, it’s okay to skip it. 
    • Follow the arrows to move through the survey. Some arrows point you to the next question. Other arrows come with a note telling you which question to answer next. They might tell you to skip over some questions. Here are some examples: 
Example Survey Items
	
1a.	Have you ever answered a mail survey questionnaire before?
0	No 	GO TO QUESTION 2
1	Yes

1b.	When was the last time you answered a mail survey questionnaire?
1	1-5 months ago
2	6-12 months ago
3	More than 12 months ago


2.	Have you ever answered a telephone survey questionnaire before?
0	No
1	Yes

OMB No.: 0925-0642
Expiration Date: 9/30/2014
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by telephone to complete this instrument so that we can identify potential sources of measurement or response error. The purpose of this instrument is to examine psychosocial, generational, and environmental correlates of cancer preventive behaviors.

Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0642). Do not return the completed form to this address.



Section 1: Your Attitudes & Opinions 
This next set of questions asks you about your views on certain types of foods.
    1. About how many servings of fruits and vegetables do you think a person should eat each day for good health?	
I’m not really sure……        OR  ______ servings each day (WRITE IN NUMBER)






    2. Please mark how much you disagree or agree with each of the statements listed below. 

Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. I feel confident in my ability to eat fruits and vegetables every day.	





    b. My friends eat fruits and vegetables most days of the week	





    c. My friends encourage me to eat fruits and vegetables	





    3. There are lots of reasons why people would eat fruits and vegetables every day. Please mark how much you disagree or agree with each of the statements listed below.
I would eat fruits and vegetables every day because…

Strongly disagree

Somewhat disagree
Neither disagree nor agree

Somewhat agree

Strongly agree






    a. I would feel bad about myself if I didn’t	





    b. I enjoy eating fruits and vegetables	





    c. I would feel like I failed if I didn’t	





    d. They help me feel better	





    e. I have thought about it and decided that I want to eat fruits and vegetables every day	





    f. Others would be upset with me if I didn’t	





    g. It’s an important thing for me to do	





    4. 
    5. There are lots of things that can prevent people from eating fruits and vegetables as much as they’d like to. Please mark how much you disagree or agree with each of the statements listed below.
I don’t eat fruits and vegetables as much as I like to because…
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. I don’t like how they taste	





    b. They cost too much	





    c. They often spoil before I get a chance to eat them	





    d. They take too much time to prepare	





    e. They aren’t filling enough	





    f. My family doesn’t like them	





    g. The restaurants I go to don’t serve fruits and vegetables	





    h. I don’t know how to choose fruits and vegetables	





    i. I have trouble digesting them	





    j. I just don’t think of  fruits and vegetables when I’m looking for something to eat	





    k. They are too messy	





    l. They are not packed in my lunch	





    m. We don’t have them in our home	





    n. My school cafeteria doesn’t serve them	






This next set of questions asks about your views on junk food and sugary drinks. Junk foods are foods that are high in calories and usually have added sugars and fat and include candy, cookies, potato chips, French fries, etc. Sugary drinks include regular soda, sports drinks, fruit drinks, sweetened teas and other drinks with added sugar. 
    6. Please mark how much you disagree or agree with each of the statements listed below.

Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. I feel confident in my ability to limit the amount of junk food and sugary drinks I eat and drink every day.	





    b. My friends eat junk food or sugary drinks on most days of the week	





    c. My friends encourage me to eat or drink junk food or sugary drinks	





    7. There are lots of reasons why people would try to limit the amount of junk food and sugary drinks they have. Please mark how much you disagree or agree with each of the statements listed below
I would try to limit how much junk food and sugary drinks I have because…
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. I would feel bad about myself if I didn’t	





    b. I would feel like I failed if I didn’t	





    c. I have thought about it and decided that I want to limit junk food and sugary drinks	





    d. Others would be upset with me if I didn’t	





    e. It’s an important thing for me to do	





    8. 
    9. There are lots of reasons why people start eating or continue eating when they aren’t hungry. How often do you start or continue to eat when you’re not hungry because…

Never
Rarely
Sometimes
Often
Always






    a. Food looks, tastes or smells good?	





    b. Others are eating?	





    c. You feel sad or depressed?	





    d. You feel bored?	





    e. You feel angry or frustrated?	





    f. You feel tired?	





    g. You feel anxious or nervous?	





    10. Please think about messages you see or hear on television, magazines, radio, Internet or billboards about foods and drinks. Please mark how much you disagree or agree with each of the statements listed below. 
When I see advertisements for foods or drinks…
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. I want to try the advertised foods or drinks.	





    b. I think the advertised foods or drinks will taste good.	





    c. I trust the messages advertised.	






Section 2: Your Preferences
The questions in this first section ask about your food and drink preferences.
    11. Please mark how much you dislike or like each of the drinks listed below.

Strongly dislike
Somewhat dislike
Neither dislike nor like
Somewhat like
Strongly like
Never tried it







    a. Sweetened fruit drinks and teas like Kool-Aid, Capri Sun, Sunny D, FUZE, Arizona Tea, etc..	






    b. 100% pure fruit juice like orange, mango, apple, grape and pineapple juices.	






    c. Regular soda or pop like Coke, Pepsi, Sprite, Dr. Pepper, root beer, etc..	






    d. Energy drinks like Rockstar, NOS, Red Bull, Amp, Monster, 5-hour Energy, Full Throttle, etc.	






    e. Sports drinks like Gatorade, Powerade, etc..	






    f. Sweetened coffee drinks with cow’s milk, soy or rice milk, like hot, refrigerated and frozen lattes, mochas, Frappuccinos, Macchiatos, etc..	






    g. Tap water, unsweetened bottled water or unsweetened sparkling water.	






    h. Milk to drink or on cereal. Count milk you drink at school. .	









    12. Please mark how much you dislike or like each of the foods listed below.

Strongly dislike
Somewhat dislike
Neither dislike nor like
Somewhat like
Strongly like
Never tried it







    a. Fruit, like apples, bananas, melon, etc.  Count fresh, frozen, canned or dried fruit.	






    b. Green leafy or lettuce salad, with or without other vegetables.	






    c. Fried potatoes, like French fries, tater tots, hash brown potatoes, etc.	






    d. Any other kind of potatoes that aren’t fried like baked, boiled, mashed or potatoes used in soups and stews.	






    e. Other non-fried vegetables like carrots, broccoli, collards, green beans, corn, etc..	






    f. Refried beans, baked beans, pinto beans, black beans or other cooked beans.	






    g. Pizza like frozen, fast food or homemade pizza.	






    h. Foods that you heat and serve or make from a box like fried mozzarella sticks, Hot Pockets, macaroni & cheese, etc. Count foods that are made at home or purchased out.	






    i. Tacos, burritos, nachos, taquitos, enchiladas, etc...	






    j. Processed meat like hot dogs, corn dogs, lunch meats (like lunchables), ham, bacon, sausage, etc. Count processed meats eaten in sandwiches.	






    k. Hamburgers and cheeseburgers made at home or purchased out. Count fast food burgers like Big Macs, Whoppers, etc.	






    l. Fried chicken like chicken nuggets, breaded chicken strips and breaded chicken patties. Count only chicken that has been fried	






    m. Whole grain bread, like toast, rolls or sandwich bread. Count whole wheat, rye, oatmeal and pumpernickel bread.	








Strongly dislike
Somewhat dislike
Neither dislike nor like
Somewhat like
Strongly like
Never tried it









    n. Brown rice or other cooked whole grains. Count bulgur, cracked wheat or millet.	







    o. Chocolate or any other type of candy. Count candy bars, lollipops/suckers, sour candies, etc..	







    p. Hot breakfast foods like pancakes, waffles, French toast, French toast sticks, etc..	






    q. Pastries like doughnuts, pop-tarts, muffins, honey buns, etc.	






    r. Cookies, cakes, cupcakes, pie or brownies. Count homemade and packaged treats like Little Debbie, Hostess Twinkies, etc.	







    s. Yogurt. Count yogurt in a carton, squeeze tube and drinkable kinds.	







    t. Ice cream or other frozen desserts like frozen yogurt, shakes, ice cream sandwiches, sherbet, etc.	







    u. Regular potato chips, corn chips or cheese puffs like Lays, Doritos, Cheetos, etc. 	







    v. Sugary cereals like Cap’n Crunch, Froot Loops, Cocoa Krispies, Cinnamon Toast Crunch, Frosted Flakes, etc.	







    w. Non-sugar-coated cereals like plain Shredded Wheat, Regular Cheerios, Chex, Corn Flakes, etc.	







    x. Hot cereals like oatmeal, grits, Cream of Wheat, etc.	









    13. Please mark the foods and drinks you never eat or drink. Please mark all that apply.
 Peanuts, peanut butter, peanut oil
 Other nuts
 Cow’s milk or other dairy products
 Soy milk or other soy foods
 Eggs or egg products
 Red meat
 Pork
 Fish or shellfish
 Chicken or turkey
 Wheat or gluten products
 Carbs or starchy foods
 Fruit or fruit juice
 Artificial colors or sweeteners
 Sweets or sugary foods
 Processed foods
 Added fats like butter, oil or mayo
 Other food: _____________________
 I don’t avoid any foods      GO TO SECTION 3
    14. Think about the foods you never eat. Why don’t you eat them? Please mark all that apply.
 Food allergies or intolerances 
 Religious beliefs
 Health concerns 
 Ethical concerns

Section 3: Food Away from Home
    15. Think about all the meals and snacks you ate and drank away from home in the past 7 days, from the time you got up until you went to bed. Please count breakfast, lunch, dinner and snacks. 
During the past 7 days, on how many days did you eat at least one meal or snack from…
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days









    a. A fast food restaurant like McDonald’s, Taco Bell or KFC? 	








    b. A sandwich or sub shop like Subway, Panera or Quiznos? 	








    c. A pizza place or restaurant like Pizza Hut, Domino’s or Papa John’s? 	








    d. A bagel or coffee shop like Starbucks, Einstein Bagels, etc.?	








    e. A snack bar in stores like Target, Wal-Mart or K-Mart?	








    f. A vending machine?	








    g. A convenience store like 7-Eleven or Express Mart?	








    h. A sit-down restaurant like Red Lobster, TGI-Fridays, Chili’s or an independent restaurant?	









Section 4: Food in Your Home
The next few questions ask about eating and food in your home. For this survey, home means the place where you and your parent(s) have lived together for most of the time in the past 12 months. 
Again, “parent” means the adult who takes care of you. It could be your birth mother or father or your adopted mother or father. It could also be your guardian, an adult relative or an adult who isn’t related to you.
    16. Please think about the evening meals you’ve eaten at home with your family in the past 7 days. 


On how many days was your evening meal or dinner…

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days











    a. Purchased from a fast food restaurant and eaten at home?	









    b. Purchased from a full service  restaurant like Applebee’s or Chili’s and eaten at home? 	









    c. Delivered to your home, like pizza or sandwiches?	









    d. Was a ready-made meal like Spaghetti-O’s, a microwave meal or frozen pizza, eaten at home?	









    e. Cooked from scratch or a recipe and eaten at home?	









    f. Eaten at home with one of your parent(s)?	









    17. 
    18. How often are the following foods and drinks available in your home?

Never
Rarely
Sometimes
Often
Always






    a. Fruits or vegetables	





    b. Sweets like candy, cookies, cake, ice cream, etc.	





    c. Sugary drinks like regular soda, sports drinks, fruit drinks, sweetened teas and other drinks with added sugar	





    d. Regular potato chips, corn chips or cheese puffs like Lays, Doritos, Cheetos, etc.	







Section 5. Family Meals
    19. Think about meal times with your family. Please mark how much you disagree or agree with each of the statements listed below.
In my family…
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat Agree
Strongly agree






    a. It is important that we eat at least one meal a day together	





    b. There are rules about mealtimes that we are expected to follow	





    c. Different schedules make it hard for us to eat meals together	





    d. We often watch TV while eating dinner	





    e. I enjoy eating meals with my family	





    f. I often eat alone	






Section 6: What You Eat and Drink
These questions ask about what you drank during the past week.  Think about everything you drank from the time you got up until you went to bed.  Be sure to count what you drank at home, school, restaurants or anywhere else.  Also think about drinks you had in a can, bottle or glass. 
    20. During the past week, how often did you drink the following:

Please mark only one box for each item. 
Didn’t drink in the past week
1 – 3 times in the past week
4 – 6 times in the past week
1 time per day
2 times per day
3 or more times per day







    a. Sweetened fruit drinks and sweetened teas like Kool-Aid, Capri Sun, Sunny D, FUZE, Arizona Tea, etc. Don’t count 100% pure fruit juice or artificially sweetened or diet drinks.	






    b. 100% pure fruit juice like orange, apple, grape and pineapple juices. Don’t count fruit-flavored drinks with added sugar like Kool-Aid, Capri Sun, etc.	






    g. Regular soda or pop like Coke, Pepsi, Sprite, Dr. Pepper, root beer, etc.  Don’t count diet or zero calorie sodas.	






    h. Energy drinks like Rockstar, NOS, Red Bull, Amp, Monster, 5-hour Energy Full Throttle etc. These drinks usually have caffeine.	






    i. Sports drinks like Gatorade, Powerade, etc. These drinks usually don’t have caffeine.  Don’t count low-calorie sports drinks like G2, Powerade Zero, etc.	






    j. Sweetened coffee drinks with cow’s milk, soy or rice milk, like hot, refrigerated and frozen lattes, mochas, Frappuccinos, Macchiatos, etc. Don’t count regular coffee without sugar.	






    k. Water or unflavored sparkling water. Count water from the sink, fountain, bottle or can. 	






    l. Milk you drink by itself or have on your cereal. Count milk you drank at school. Don’t count small amounts of milk added to coffee or tea.	







    21. When you drink milk, what type is it most of the time? 
 Plain or white milk (cow’s milk)
 Flavored or sweetened cow’s milk (like chocolate, vanilla, strawberry, etc.) 
 Other type like soy, rice, almond milk, etc.
 Don’t drink milk     GO TO QUESTION 20
    22. What kind of milk do you usually drink? Please mark only one box below.
 Whole or regular milk (red top)
 2% fat or reduced-fat
 1% or low-fat
 Fat-free, skim or nonfat
 Don’t know
These questions ask about the food you ate during the past week.  Think about all the food you ate from the time you got up until you went to bed.  Be sure to count food that you ate at home, school, restaurants or anywhere else.  
    23. During the past week, how often did you eat the following:
Please mark only one box for each item.
Didn’t drink in the past week
1 – 3 times in the past week
4 – 6 times in the past week
1 time per day
2 times per day
3 or more times per day







    a. Fruit, like apples, bananas, melon, etc. Count fresh, frozen, canned and dried fruit. Don’t count fruit juices.	






    b. A Green leafy or lettuce salad, with or without other vegetables.	






    c. Fried potatoes, like French fries, tater tots, hash brown potatoes, etc.	






    d. Any other kind of potatoes that aren’t fried, like baked, boiled, mashed or potatoes used in soups and stews.	






    e. Other non-fried vegetables like carrots, broccoli, collards, green beans, corn, etc. Don’t count green salad or potatoes.	






    f. Refried beans, baked beans, pinto beans, black beans or other cooked beans. Don’t count green beans or string beans.	






    g. Pizza, like frozen, fast food and homemade pizza.	






    h. Foods that you heat and serve or make from a box like fried mozzarella sticks, Hot Pockets, macaroni and cheese, etc. Count foods that are made at home or purchased out.	






    i. Tacos, burritos, nachos, taquitos, enchiladas, etc.	






    j. Processed meat like hot dogs, corn dogs, lunch meats (like lunchables), ham, bacon, sausage, etc. Count processed meats eaten in sandwiches.	






    k. Hamburgers and cheeseburgers made at home or purchased out. Count fast food burgers like Big Macs, Whoppers, etc.	






    l. Fried chicken like chicken nuggets, breaded chicken strips and breaded chicken patties. Count only chicken that has been fried.	






    m. Whole grain bread, like toast, rolls and sandwich bread. Count whole wheat, rye, oatmeal and pumpernickel bread. Don’t count white bread.	






    n. Brown rice or other cooked whole grains. Count bulgur, cracked wheat or millet. Don’t count white rice.	
    o. 
    p. 






    o. Chocolate or any other types of candy. Count candy bars, lollipops/suckers, sour candies, etc. Don’t count sugar-free candy.	






    p. Hot breakfast foods like pancakes, waffles, French toast, french toast sticks, etc. Don’t count whole wheat kinds.	






    q. Pastries like doughnuts, Pop-Tarts, muffins, honey buns, etc. Don’t count sugar-free pastries.	






    r. Cookies, cakes, cupcakes, pie or brownies. Count homemade and packaged treats like Little Debbie, Hostess Twinkies, etc. Don’t count sugar-free kinds.	






    s. Yogurt. Count yogurt in a carton, squeeze tube and drinkable kinds. Don’t count frozen yogurt.	






    t. Ice cream or other frozen desserts like frozen yogurt, shakes, ice cream sandwiches, sherbet, etc. Don’t count sugar-free kinds.	






    u. Regular potato chips, corn chips or cheese puffs like Lays, Doritos, Cheetos, etc. Don’t count low-fat or baked varieties and don’t count pretzels.	






    v. Sugary cereals like Cap’n Crunch, Froot Loops, Cocoa Krispies, Cinnamon Toast Crunch, Frosted Flakes, etc. Don’t count non-sugary-coated kinds like Shredded Wheat or Regular Cheerios.	






    w. Non-sugar coated cereals like Shredded Wheat, Regular Cheerios, Chex, Corn Flakes, etc. Don’t count sugary cereals like Froot Loops or Frosted Flakes.	






    x. Hot cereals like oatmeal, grits, Cream of Wheat, etc.	







Section 7: Your Parents
Again, “parent” means the adult who takes care of you. It could be your birth mother or father or your adopted mother or father. It could also be your guardian, an adult relative or an adult who isn’t related to you.
    24. Think about what your parent(s) say and do when it comes to eating fruits and vegetables. How often is each statement true for you?

Never
Rarely
Sometimes
Often
Always






    a. My parent(s) enjoy eating fruits and vegetables 	





    b. My parent(s) buy fruits and vegetables for me	





    c. I see my parent(s) eating fruits and vegetables	





    d. My parent(s) encourage me to eat more fruits and vegetables…………………….





    e. My parent(s) encourage me to try different kinds of fruits and vegetables	





    f. My parent(s) and I decide together how many fruits and vegetables I have to eat	





    g. If my parent(s) don’t tell me to, I won’t eat enough fruits and vegetables	





    h. If my parent(s) don’t keep track, I won’t eat enough fruits and vegetables.	





    i. My parent(s) make me eat fruits and vegetables	





    j. It’s my parent(s)’ responsibility to make rules about how many fruits and vegetables I eat	






These questions ask about junk food and sugary drinks that you may eat or drink. Remember that junk foods are foods that are high in calories and usually have added sugars and fat and include candy, cookies, potato chips, French fries, etc. Sugary drinks include regular soda, sports drinks fruit drinks, sweetened teas and other drinks with added sugar.

    25. Think about what your parent(s) say and do when it comes to eating junk food or drinking sugary drinks. How often is each statement true for you?

Never
Rarely
Sometimes
Often
Always






    a. My parent(s) enjoy junk food and sugary drinks	





    b. If I’ve had a bad day, my parents let me have junk food or sugary drinks	





    c. My parent(s) offer junk food or sugary drinks as a reward for my good behavior 	





    d. My parent(s) don’t buy a lot of junk food or sugary drinks for me	





    e. My parent(s) don’t eat a lot of junk food or drink a lot of sugary drinks in front of me	





    f. My parent(s) and I decide together how much junk food or sugary drinks I can have	





    g. If my parent(s) don’t keep track, I will eat too much junk food or drink too many sugary drinks	





    h. If my parent(s) don’t limit them, I will eat too much junk food or drink too many sugary drinks	





    i. If I get in trouble or act up, my parent(s) don’t let me eat junk food or drink sugary drinks





    j. My parent(s) decide how much junk food or sugary drinks I can have	





    k. I think it’s my parent(s)’ responsibility to make rules about how much junk food or sugary drinks I have	





    26. 
    27. Now think in general about your relationship with your parent(s).  Please mark how much you disagree or agree with each of the statements listed below.

Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree






    a. My parent(s) expect me to follow family rules	





    b. My parent(s) don’t like me to share my problems	





    c. My parent(s) respect my privacy	





    d. If I don’t behave myself, my parent(s) will punish me	





    e. My parent(s) make most of the decisions about what I can do	





    f. My parent(s) believe I have a right to my own point of view	





    g. I can count on my parent(s) to help me out if I have a problem	





    h. My parent(s) let me get away with things	





    i. My parent(s) point out ways I could do better	





    j. My parent(s) and I do fun things together	





Thank you for taking the time to complete this survey. Your answers are important to us!
INSTRUCTIONS FOR RETURNING COMPLETED SURVEY








General Information about You
We are interested in some general information about you.  Your answers to these questions are important to us.  They will help us better understand your answers to other parts of the survey.
    1. What is your age? 
 11 years old
 12 years old
 13 years old
 14 years old
 15 years old
 16 years old
 17 years old
 18 years old
    2. Are you male or female?
 Male  			
Female 
    3. What grade are you in?
 6th grade or less 
 7th grade
 8th grade
 9th grade
 10th grade
 11th grade 
 12th grade
 Ungraded or other grade
    4. During the past school year, what kind of school were you enrolled in?
 Public School
 Private School
 Home-schooled
    5. Are you Hispanic, Latino/a or Spanish origin? 
  Yes			
 No 
    6. Which one or more of the following would you say is your race? Please mark all that apply.
 American Indian or Alaska Native 
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
    7. Were you born in the United States?
  Yes     GO TO QUESTION 9	
 No 
    8. If not, in what year did you come to the United States to stay? ___ ___ ___ ___
    9. What languages do you speak at home? Please mark all that apply.
 English
 Spanish
 Cantonese
 Vietnamese
 Tagalog
 Mandarin 
 Korean
 Asian Indian languages
 Russian
 Other Language: ________________
    10.  How would you rate your ability to read?
 Very poor
 Poor
 Okay
 Good
 Very good
    11. How often do you need help reading information from your doctor or pharmacy?
 Never
 Rarely
 Sometimes
 Often
 Always
    12. How many hours a week do you get paid to work? 
 I don’t work for pay
 1-9 hours 
 10-19 hours
 20-29 hours
 30-39 hours
 40 hours
 More than 40 hours 
Please also answer a few questions about your general health.
    13. In general, would you say your health is…
 Excellent
 Very good
 Good
 Fair
 Poor
    14. What is your height and weight without shoes?
Height: Feet _______ Inches_______
Weight: Pounds ____________
 Don’t Know
    15. Overall, how would you rate your current weight? 
 I’m very underweight
 I’m a little underweight
 My weight is just right
 I’m a little overweight
 I’m very overweight
    16. Are you currently trying to…
 Lose weight
 Gain weight
 Stay the same weight

How much do you disagree or agree with each of the statements listed below: 
    17. I eat a healthy diet.
 Strongly disagree
 Somewhat disagree
 Neither disagree nor agree
 Somewhat agree
 Strongly agree
    18. I stay at a healthy weight.
 Strongly disagree
 Somewhat disagree
 Neither disagree nor agree
 Somewhat agree
 Strongly agree
    19. People tease me about my weight. 
 Strongly disagree
 Somewhat disagree
 Neither disagree nor agree
 Somewhat agree
 Strongly agree