Health and Wellness Survey

Instructions

Answer all of the questions as they relate to you and be truthful with your responses.

Please enter your survey verification code

What is your gender?

	Male
	Female

What grade are you in?

	7
	8
	9

How often do you eat breakfast before coming to school?

	Never
	Rarely
	1-2 times a week
	3-4 times a week
	Everyday

If you are unable to eat breakfast, what are the reasons for you missing breakfast?

	I eat breakfast in the morning
	Not enough time
	Not hungry in the morning
	No food available for breakfast

Did you know that Montague Intermediate provides a Breakfast Club in the mornings?

	Yes
	No

How many times have you eaten breakfast at the Montague Intermediate Breakfast Club?

	Never
	1-5 times
	11-15 times
	More than 15 times

How many meals do you eat each day?

	No meals
	1 meal
	2 meals
	3 meals
	More than 3 meals a day

Please look at the image below and answer the questions related to food servings.

No servings

1-2 servings

3-4 servings

5 or more servings

How many servings of fruit and vegetables do you eat each day?

How many servings of milk or milk products do you consume each day?

How many servings of grain products do you eat each day?

How many servings of meat or meat products do you eat each day?

How often do you leave the school to eat lunch?

	I don�t leave the school for lunch
	1-2 times a week
	3-4 times a week
	Everyday

If you do leave the school at lunch time, what types of foods do you purchase?

Yes

No

Burgers and Fries?

Pizza?

Salad?

Subs?

Chips?

Pop?

Chocolate Bars?

Leave School - Other

List any other foods that you purchase outside school?

If you stay at school to eat your lunch, how often do you buy the healthy lunch provided on Thursdays?

	Never
	Once
	Occasionally
	Every Week

How many times have you purchased the healthy snack provided on Wednesdays?

	Never
	1-2 times
	3-4 times
	5-6 times
	Every week

Have you made purchases from the school canteen?

	Yes
	No

What types of food do you purchase at the Montague Intermediate canteen?

Yes

No

Fruit?

Cheese?

Ice Cream?

Granola bars?

Pretzels?

Rice Krispie Squares?

Gold Fish/Sun Chips snacks?

As a student you receive a lot of information about health and safety that makes an impact on your life like seat belts save lives, smoking causes cancer, etc. In what ways do you personally practice healthy eating?

Are you a member of an organized sports team (either in school or in the community)?

	Yes
	No

How often do you participate in physical activity each week in which you are active for 30 minutes or more?

	Never
	1-2 times
	3-4 times
	5 or more times

Do you consider yourself to be in good physical condition?

	Yes
	No

If you are unable to take part in regular physical activity, what are the reasons?

	I participate in physical activity
	No interest
	No time
	No confidence to participate in physical activity
	Other:

Do you feel that you are �stressed out� often?

	Yes
	No

Do you have ways to deal with your stress?

	Yes
	No

If you find that you are often �stressed out�, how do you deal with it?

Yes

No

Physical activity?

Reading

Playing video games/Watching TV

Talk to my friends?

List any other ways that you deal with stress

Do you feel depressed often?

	Yes
	No

Do you smoke cigarettes?

	Yes
	No

If Yes, how many cigarettes do you smoke each day?

	1-4
	5-10
	More than 10

Never

Tried it a few times

Regular basis - on the weekends

More than once a week

How often do you drink alcohol?

How often do you use drugs other than alcohol?