5210 Healthy Habits Questionnaire (Ages 2-9)
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15210 Healthy Habits Questionnaire
(Ages 2–9)
We are interested in the health and well-being of all our patients. Please take a moment to answer the following questions.
Patient Name: _________________________________________________________
Age: __________ Today’s Date: __________
1. How many servings of fruits or vegetables does your child eat a day?
__________________________
One serving is most easily identified by the size of the palm of your child’s hand.
2. How many times a week does your child eat dinner at the table
together with the family?
__________________________
3. How many times a week does your child eat breakfast?
__________________________
4. How many times a week does your child eat takeout or fast food?
__________________________
5. How many hours a day does your child watch TV/movies or sit and play
video/computer games?
__________________________
6. Does your child have a TV in the room where he /she sleeps?
Yes
No
7. Does your child have a computer in the room where he /she sleeps?
Yes
No
8. How much time a day does your child spend in active play
(faster breathing/heart rate or sweating)?
__________________________
9. How many 8-ounce servings of the following does your child drink a day?
100% Juice _______
Fruit drinks or sports drinks _______
Soda or punch
_______
Water
_______
Whole milk
_______
Nonfat or reduced fat milk _______
10. Based on your answers, is there ONE thing you would like to help your child change now? Please check one box.
Eat more fruits & vegetables.
Spend less time watching TV/movies and playing video/computer 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 skim or low fat milk.
Drink more water.
Please give the completed form to your clinician. Thank you.
Adapted by MaineHealth
®
and Maine Medical Center from the
High Five for Kids in Massachusetts and Keep ME Healthy in Maine.
155-505-08 / 03-31-08
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