Adapted from 5210 LET’S 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: ______________ Today’s 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 child’s 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.