Form 2 Parent Diet and Demographic Survey

ATTACHMENT 4A-1 FLASHE PARENT 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.

• In the first part of the survey we will ask questions about you. In the second part, we will ask questions about your teenager, {FILL TEENAGER’S NAME}.

• 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	1  b. 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.

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FLASHE Diet Survey: Parent

ection 1: Your Attitudes and 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 this statement: I feel confident in my ability to eat fruits and vegetables every day.

Strongly disagree

Somewhat disagree

Neither disagree nor agree

Somewhat agree

Strongly agree

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 because…	S trongly disagree	S omewhat disagree	N either disagree nor agree	S omewhat agree	Strongly agree
   I would feel bad about myself if I didn’t
   I enjoy eating fruits and vegetables
   I would feel like I failed if I didn’t
   They help me feel better
   I have thought about it and decided that I want to want to eat fruits and vegetables every day
   Others would be upset with me if I didn’t
   It’s an important thing for me to do

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
I don’t like how they taste
They cost too much
They often spoil before I get a chance to eat them
They take too much time to prepare
They aren’t filling enough
My family doesn’t like them
The restaurants I go to don’t serve fruits and vegetables
I don’t know how to choose fruits and vegetables
I have trouble digesting them
I just don’t think of fruits and vegetables when I’m looking for something to eat
They are too messy
Fruits contain too much sugar

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

Strongly disagree

Somewhat disagree

Neither disagree nor agree

Somewhat agree

Strongly agree

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
   I would feel bad about myself if I didn’t
   I would feel like I failed if I didn’t
   Limiting junk food and sugary drinks helps me feel better
   I have thought about it and decided that I want to limit junk food and sugary drinks
   Others would be upset with me if I didn’t
   It’s an important thing for me to do

8. 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
   Food looks, tastes or smells good?
   Others are eating?
   You feel sad or depressed?
   You feel bored?
   You feel angry or frustrated?
   You feel tired?
   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. Pease 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
I want to try the advertised foods or drinks.
I think the advertised foods or drinks will taste good.
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
Sweetened fruit drinks and teas like Kool-Aid, Capri Sun, Sunny D, FUZE, Arizona Tea, etc.
100% pure fruit juice like orange, mango, apple, grape and pineapple juices.
Regular soda or pop like Coke, Pepsi, Sprite, Dr. Pepper, root beer, etc.
Energy drinks like Rockstar, NOS, Red Bull, Amp, Monster, 5-hour Energy, Full Throttle, etc.
Sports drinks like Gatorade, Powerade, etc..
Sweetened coffee drinks with cow’s milk, soy or rice milk, like hot, refrigerated and frozen lattes, mochas, Frappuccinos, Macchiatos, etc..
Tap water, unsweetened bottled water or unsweetened sparkling water.
Milk to drink or on cereal. .

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
Fruit, like apples, bananas, melon, etc. Count fresh, frozen, canned or dried fruit.
Green leafy or lettuce salad, with or without other vegetables.
Fried potatoes, like French fries, tater tots, hash brown potatoes, etc.
Any other kind of potatoes that aren’t fried like baked, boiled, mashed or potatoes used in soups and stews.
Other non-fried vegetables like carrots, broccoli, collards, green beans, corn, etc.
Refried beans, baked beans, pinto beans, black beans or other cooked beans.
Pizza like frozen, fast food or homemade pizza.
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.
Tacos, burritos, nachos, taquitos, enchiladas, etc...
Processed meat like hot dogs, corn dogs, lunch meats (like lunchables), ham, bacon, sausage, etc. Count processed meats eaten in sandwiches.
Hamburgers and cheeseburgers made at home or purchased out. Count fast food burgers like Big Macs, Whoppers, etc.
Fried chicken like chicken nuggets, breaded chicken strips and breaded chicken patties. Count only chicken that has been fried
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
Brown rice or other cooked whole grains. Count bulgur, cracked wheat or millet.
Chocolate or any other type of candy. Count candy bars, lollipops/suckers, sour candies, etc.
Hot breakfast foods like pancakes, waffles, French toast, French toast sticks, etc..
Pastries like doughnuts, pop-tarts, muffins, honey buns, etc.
Cookies, cakes, cupcakes, pie or brownies. Count homemade and packaged treats like Little Debbie, Hostess Twinkies, etc.
Yogurt. Count yogurt in a carton, squeeze tube and drinkable kinds.
Ice cream or other frozen desserts like frozen yogurt, shakes, ice cream sandwiches, sherbet, etc.
Regular potato chips, corn chips or cheese puffs like Lays, Doritos, Cheetos, etc.
Sugary cereals like Cap’n Crunch, Froot Loops, Cocoa Krispies, Cinnamon Toast Crunch, Frosted Flakes, etc.
Non-sugar-coated cereals like plain Shredded Wheat, Regular Cheerios, Chex, Corn Flakes, etc.
Hot cereals like oatmeal, grits, Cream of Wheat, etc.

14. 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 other poultry

Wheat or gluten products

Carbs or starchy foods

Fruit or fruit juice

Artificial colors or sugars

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

15. 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

16. 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 fast food restaurant like McDonald’s, Taco Bell or KFC?
A sandwich or sub shop like Subway, Panera or Quiznos?
A pizza place like Pizza Hut, Domino’s or Papa John’s?
A bagel or coffee shop like Starbucks, Einstein Bagels, etc.?
A snack bar in stores like Target, Wal-Mart or K-Mart?
A vending machine?
A convenience store like 7-Eleven or Express Mart?
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 food in your home. For this survey, home means the place where you and {FILL TEENAGER’S NAME} have lived for most of the time in the past 12 months.

17. 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
    Purchased from a fast food restaurant and eaten at home?
    Purchased from a full service restaurant like Applebee’s or Chili’s and eaten at home?
    Delivered to your home, like pizza or sandwiches?
    A ready-made meal like Spaghetti-O’s, a microwave meal or frozen pizza, eaten at home?
    Cooked from scratch or a recipe and eaten at home?

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

	Never	Rarely	Sometimes	Often	Always
Fruits or vegetables
Sweets like candy, cookies, cake, ice cream, etc.
Sugary drinks like regular soda, sports drinks, fruit drinks, sweetened teas and other drinks with added sugar
Regular potato chips, corn chips or cheese puffs like Lays, Doritos, Cheetos, etc...

These next questions are about the food eaten in your household in the past 12 months and whether you were able to afford the food you needed.

19. For the following statements, please mark whether the statement was never true, sometimes true or always true for you or someone in your household in the past 12 months.

    	Never true	Sometimes true	Always true	Don’t know
    The food we bought just didn’t last and we didn’t have the money to get more
    We couldn’t afford to eat balanced meals

20. In the past 12 months, did you or others in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?

Yes

No GO TO QUESTION 19

21. If yes, how often did this happen?

Almost every month

Some months but not every month

Only 1 or 2 months

Don’t know

22. In the past 12 months, did you or anyone in your household ever eat less than you felt you should because there wasn’t enough money for food?

Yes

No

Don’t Know

23. In the past 12 months, were you or was anyone in your household ever hungry but didn’t eat because there wasn’t enough money for food?

Yes

No

Don’t Know

Section 5. Family Meals

24. 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
    It is important that we eat at least one meal a day together
    Different schedules make it hard for us to eat meals together
    We often watch TV while eating dinner
    I enjoy eating meals with my family

25. 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
I do most of the cooking for my family
Cooking takes too much time
I like cooking
My family doesn’t like my cooking

26. Please mark how often you….

	Never	Rarely	Sometimes	Often	Always	Doesn’t apply
Make a list before you go shopping
Read the detailed food labels or nutrition facts

Section 6: What you Eat and Drink

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hese 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, work, restaurants or anywhere else. Also think about drinks you had in a can, bottle or glass.

27. 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
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.
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.
Regular soda or pop like Coke, Pepsi, Sprite, Dr. Pepper, root beer, etc. Don’t count diet or zero calorie sodas.
Energy drinks like Rockstar, NOS, Red Bull, Amp, Monster, 5-hour Energy Full Throttle etc. These drinks usually have caffeine.
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.
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.
Water or unflavored sparkling water. Count water from the sink, fountain, bottle or can.
Milk you drink by itself or have on your cereal. Don’t count small amounts of milk added to coffee or tea.

28. 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 27

29. 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, work, restaurants or anywhere else.

30. 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
Fruit, like apples, bananas, melon, etc. Count fresh, frozen, canned and dried fruit. Don’t count fruit juices.
A Green leafy or lettuce salad, with or without other vegetables.
Fried potatoes, like French fries, tater tots, hash brown potatoes, etc.
Any other kind of potatoes that aren’t fried, like baked, boiled, mashed or potatoes used in soups and stews.
Other non-fried vegetables like carrots, broccoli, collards, green beans, corn, etc. Don’t count green salad or potatoes.
Refried beans, baked beans, pinto beans, black beans or other cooked beans. Don’t count green beans or string beans.
Pizza, like frozen, fast food and homemade pizza.
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.
Tacos, burritos, nachos, taquitos, enchiladas, etc.
Processed meat like hot dogs, corn dogs, lunch meats (like lunchables), ham, bacon, sausage, etc. Count processed meats eaten in sandwiches.
Hamburgers and cheeseburgers made at home or purchased out. Count fast food burgers like Big Macs, Whoppers, etc.
Fried chicken like chicken nuggets, breaded chicken strips and breaded chicken patties. Count only chicken that has been fried.
Whole grain bread, like toast, rolls and sandwich bread. Count whole wheat, rye, oatmeal and pumpernickel bread. Don’t count white bread.
Brown rice or other cooked whole grains. Count bulgur, cracked wheat or millet. Don’t count white rice.
Chocolate or any other types of candy. Count candy bars, lollipops/suckers, sour candies, etc. Don’t count sugar-free candy.
Hot breakfast foods like pancakes, waffles, French toast, french toast sticks, etc. Don’t count whole wheat kinds.
Pastries like doughnuts, Pop-Tarts, muffins, honey buns, etc. Don’t count sugar-free pastries.
Cookies, cakes, cupcakes, pie or brownies. Count homemade and packaged treats like Little Debbie, Hostess Twinkies, etc. Don’t count sugar-free kinds.
Yogurt. Count yogurt in a carton, squeeze tube and drinkable kinds. Don’t count frozen yogurt.
Ice cream or other frozen desserts like frozen yogurt, shakes, ice cream sandwiches, sherbet, etc. Don’t count sugar-free kinds.
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.
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.
Non-sugar coated cereals like Shredded Wheat, Regular Cheerios, Chex, Corn Flakes, etc. Don’t count sugary cereals like Froot Loops or Frosted Flakes.
Hot cereals like oatmeal, grits, Cream of Wheat, etc.

Section 7. Your Teenager

This next part of the survey asks you to think about {FILL TEENAGER’S NAME}’s eating habits. Remember to answer only for {FILL TEENAGER’S NAME}.

31. How often is each statement true regarding your views on fruits and vegetables for {FILL TEENAGER’S NAME}?

	N ever	R arely	S ometimes	O ften	A lways
My teenager enjoys eating fruits and vegetables
My teenager eats enough fruits and vegetables
I buy fruits and vegetables for my teenager
I try to eat fruits and vegetables in front of my teenager.
I encourage my teenager to eat more fruits and vegetables
I encourage my teenager to try different kinds of fruits and vegetables
My teenager and I decide together how many fruits and vegetables he/she has to eat
If I don’t keep track, my teenager won’t eat enough fruits and vegetables
I make my teenager eat fruits and vegetables
It’s my responsibility to make rules about how many fruits and vegetables my teenager eats

These questions ask about junk food and sugary drinks that your teenager 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.

32. How often is each statement true regarding your views on junk food and sugary drinks for {FILL TEENAGER’S NAME}?

    	Never	Rarely	Sometimes	Often	Always
    My teenager enjoys junk food and sugary drinks
    If my teenager has a bad day, I let him/her eat junk food or drink sugary drinks
    I offer junk food or sugary drinks as a reward for my teenager’s good behavior
    I don’t buy a lot of junk food or sugary drinks for my teenager
    I try to limit how much junk food or sugary drinks I eat and drink in front of my teenager
    My teenager and I decide together how much junk food or sugary drinks he/she can eat or drink
    If I don’t keep track, my teenager will eat too much junk food or drink too many sugary drinks
    If I don’t limit them, my teenager will eat too much junk food or drink too many sugary drinks
    If my teenager gets in trouble or acts up, I don’t let him/her eat junk food or drink sugary drinks
    I decide how much junk food or sugary drinks my teenager can eat or drink
    It’s my responsibility to make rules about how much junk food or sugary drinks my teenager can eat or drink

34. Now think in general about how you parent {FILL TEENAGER’S NAME}. 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
I expect my teenager to follow family rules
I encourage my teenager to share his/her troubles
I respect my teenager’s privacy
If my teenager doesn’t behave him/herself, he/she will be in trouble
I make most of the decisions about what my teenager can do
I believe my teenager has a right to his/her own point of view
My teenager can count on me if he/she has a problem
I let my teenager get away with things
I point out ways my teenager could do better
My teenager 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

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FLASHE Demographics Survey: Parent

eneral 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? _________

2. Are you male or female?

Male

Female

3. What is the highest grade or level of education you completed?

Less than a high school degree

A high school degree or GED

Some college but not a college degree

A 4-year college degree or higher

4. What is your marital status?

Married

Divorced

Widowed

Separated

Never married

A member of an unmarried couple

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 live in the United States? ___ ___ ___ ___

9. About how long have you lived at your current address?

______ Months _______ Years

10. Do you currently rent or own your home?

Own

Rent

Occupied without paying monetary rent

11. How often in the past 12 months would you say you were worried or stressed about having enough money to pay for your rent or mortgage?

Never

Almost never

Sometimes

Fairly often

Very often

12. What is your current employment status? Are you...

Employed for wages

Self-employed

Out of work for more than 1 year GO TO QUESTION 14

Out of work for less than 1 year GO TO QUESTION 14

A homemaker GO TO QUESTION 14

A student GO TO QUESTION 14

Retired GO TO QUESTION 14

13. About how many hours do you work per week at all of your jobs and businesses combined?

________ Hours

14. Thinking about members of your family living in your household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past 12 months?

$0 to $9,999

$10,000 to $14,999

$15,000 to $19,999

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $199,999

$200,000 or more

15. Are you currently receiving food stamp assistance, such as Supplemental Nutrition Assistance Program (SNAP), Women, Infants and Children (WIC), Temporary Assistance for Needy Families (TANF) or Supplemental Security Income (SSI)?

Yes

No

Don’t know

16. What languages do you usually speak at home? Please mark all that apply.

English

Spanish

Cantonese

Vietnamese

Tagalog

Mandarin

Korean

Asian Indian languages

Russian

Other Language: ___________________

17. In what languages are the TV shows, radio stations or newspapers that you usually watch, listen to or read?

Only another language

More of another language than English

Another language and English about the same

More English than another language

Only English

18. How would you rate your ability to read English?

Very poor

Poor

Okay

Good

Very good

19. How often do you need to have someone help you read written material from your doctor or pharmacy?

Never

Rarely

Sometimes

Often

Always

20. How many children under the age of 18 live in your household? _____________

21. Does your teenager currently receive free or reduced price lunch at school?

Yes

No

Don’t know

Please also answer a few questions about your general health.

22. In general, would you say your health is…

Excellent

Very good

Good

Fair

Poor

23. What is your height and weight without shoes?

Height: Feet _______ Inches_______

Weight: Pounds ____________

Don’t Know

24. 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

25. Are you currently trying to…

Lose weight

Gain weight

Stay the same weight

31