Conceptual

Adapted from the North Carolina Department of Health & Human Services (2004)

Heather Alico Lauria, BSN, RN [email protected] DEMOGRAPHIC INFORMATION:

Relationship to Child:__________________ Child’s Age_________

Race:________________________________ Sex: Male [] Female []

County of Residence:___________________ Estimated Height_________ Weight_________

Number of Sessions Attended:___________

Please check one response for each question below. PHYSICAL ACTIVITY

1. ACTIVITY LEVEL - Compared to before your child participated in the Health U program, is your child

 01 - a lot more physically active than before  02 - a little more physically active than before  03 - Average - same as before

 04 - a little less physically active than before  05 - a lot less physically active than before  09 - Don’t know/not sure

2. VARIETY OF PHYSICAL ACTIVITIY- Compared to before your child participated in the Health U program, does your child do

 01 – a lot more variety of physical activity than before  02 - a little more variety of physical activity than before  03 - Average - same as before

 04 - a little less variety of physical activity than before  05 - a lot less variety of physical activity than before  09 - Don’t know/not sure

SWEETENED BEVERAGES

3. SODA BEVERAGES-- Compared to before your child participated in the Health U program, does your child drink

 01 – a lot more soda beverages than before  02 - a little more soda beverages than before  03 - Average - same as before

 04 - a little less soda beverages than before  05 - a lot less soda beverages than before

4. SWEETENED BEVERAGES-- Compared to before your child participated in the Health U program, does your child drink

 01 – a lot more sweetened beverages than before  02 - a little more sweetened beverages than before  03 - Average - same as before

 04 - a little less sweetened beverages than before  05 - a lot less sweetened beverages than before

FAST FOOD FREQUENCY/ SNACK INTAKE

5. FAST FOOD – Compared to before your child participated in the Health U program, does your child eat (Fast food such as Burger King, Chick-Fil-A, Bojangles, Pizza Hut, etc.)

 01 – a lot more fast food than before  02 - a little more fast food than before  03 - Average - same as before  04 - a little less fast food than before  05 - a lot less fast food than before

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6. HEALTHY SNACKS - Compared to before your child participated in the Health U program, does your child choose to eat (Healthy snacks=Fruits, vegetables, whole grain snacks, yogurt, nuts, etc. instead of chips, cookies, ice cream, etc.)

 01 – a lot more healthy snacks than before  02 - a little more healthy snacks than before  03 - Average - same as before

 04 - a little less healthy snacks than before  05 - a lot less healthy snacks than before

LOW FAT DAIRY INTAKE

7. LOW-FAT MILK- Compared to before your child participated in the Health U program, does your child drink

 01 – a lot more low-fat milk than before  02 - a little more low-fat milk than before  03 - Average - same as before

 04 - a little less low-fat milk than before  05 - a lot less low-fat milk than before

FRUIT AND VEGETABLE INTAKE

8. VEGETABLES - Compared to before your child participated in the Health U program, does your child eat

 01 – a lot more vegetables than before  02 - a little more vegetables than before  03 - Average - same as before

 04 - a little less vegetables than before  05 - a lot less vegetables than before

9. FRUITS - Compared to before your child participated in the Health U program, does your child eat

 01 – a lot more fruit than before  02 - a little more fruit than before  03 - Average - same as before  04 - a little less fruit than before  05 - a lot less fruit than before

KNOWLEDGE

10. NUTRITION KNOWLEDGE (ie. Food groups, making healthy choices) - Compared to before your child participated in the Health U program, does your demonstrate

 01 – a lot more knowledge about nutrition than before  02 - a little more knowledge about nutrition than before  03 - Average - same as before

 04 - a little less knowledge about nutrition than before 05 - a lot less knowledge about nutrition than before

11. PHYSICAL ACTIVITY KNOWLEDGE (ie. Importance of exercise, types of physical activity) - Compared to before your child participated in the Health U program, does your child demonstrate

 01 – a lot more knowledge about physical activity than before  02 - a little more knowledge about physical activity than before  03 - Average - same as before

 04 - a little less knowledge about physical activity than before  05 - a lot less knowledge about physical activity than before

WEIGHT

12. WEIGHT - Compared to before your child participated in the Health U program, does your child weigh

 01 – a lot more than before  02 - a little more than before  03 - Average - same as before  04 - a little less than before  05 - a lot less activity than before

Please note any other observed changes in your child’s physical activity or eating behaviors since participating in the Health U program. (ie. Child’s comments about food choices, healthy choices when eating fast food, participating in meal preparation, desire to exercise, etc.)

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