Adapted from 5210 LETS GO www.letsgo.org
Division of Adolescent Medicine 410 Lakeville Road, Suite 108 New Hyde Park, NY 11042 Phone: (516) 465-3270
Healthy Habits Questionnaire (Ages 2-9)
Patient Name: Patient Age: ______________ Todays Date__________________________________
1. How many servings of fruits does your child consume a day? ____________________________________________________________ One serving is most easily identified by the size of the palm of your childs hand.
2. How many servings of vegetables does your child consume a day? ________________________________________________________
3. How many times a week does your child eat dinner at the table together with the family? _____________________________________
4. How many times a week does your child eat breakfast? _________________________________________________________________
5. How many times a week does your child eat fast food or takeout? ________________________________________________________
6. How many hours a day does your child watch TV/movies or sit and play video/computer games?_______________________
7. Does your child have a TV in the room where he/she sleeps? _________ Yes __________ No
8. Does your child have a computer in the room where he/she sleeps? ________ Yes _________ No
9. How much time a day does your child spend being active (faster breathing, heart beating faster or sweating)?_____________________
10. How many 8 ounce servings of the following do you drink a day?
Juice _______ Soda or punch ________Sport drinks (i.e. Gatorade, Powerade, etc.)
______ Water _______Milk (please circle): Nonfat (skim) low-fat (1%) reduced- fat (2%) milk
11. Is there ONE thing you would be interested in changing now?
Eat more fruits and vegetables. ______ Spend less time watching TV/movies and playing video games.
Take the TV out of the bedroom. ______ Eat less Fast food/ takeout.
Play outside more often. ______ Drink less soda, juice, or punch.
Switch to nonfat (skim) or low- fat (1%) milk. ______ Drink more water.