form test - Think eat and move

Eating habits

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Program Code

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Child

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Survey Form

Complete this survey with help from your parent or carer. This questionnaire allows us to measure your food and drink intake before the program. It will be repeated at the end of the program and you will be given the results of this in your personalised report after the program.

How many serves of fruit do you USUALLY eat each day? This includes all fresh, dried, frozen, and tinned fruit.*

How many serves of vegetables do you USUALLY eat each day? This includes all fresh, dried, frozen and tinned vegetables.*

How much water do you USUALLY drink each day? This can be plain tap water or bottled water.*

How much soft drink, cordial or sports drink do you USUALLY drink (e.g. cordial, Coke, Lemonade, Gatorade)?*

How often do you eat hot chips, French fries, wedges or fried potatoes such as hash browns?*

How often do you have meals or snacks, such as burgers, pizza, chicken, or chips from places like McDonalds, Hungry Jacks,Pizza Hut, KFC, Red Rooster or local take-away food places?*

How many times a week do you usually eat your meal at night in front of the television (TV)?

Days a week*

I rarely / never eat in front of the TV

How often do you usually eat snack foods, such as sweet and savoury biscuits, cakes, donuts, or muesli bars?*

How often do you usually eat confectionery, such as lollies and chocolate?*

How often do you usually eat potato crisps or other salty snacks (such as Twisties or corn chips)?*