Physical Activity And Nutrition Behaviors Monitoring Form
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21. NAME
N.C. Department of Health and Human Services
Women’s and Children’s Health Section
2. HSIS ID #
Physical Activity & Nutrition Behaviors
3. Date of Birth
Monitoring Form
Month
Day
Year
8. Person Completing Form:
4. Race:
1. White
2. Black
3. Am. Indian
4. Asian
5.Native Hawaiian/Other Pacific Islander
6. Unknown
Name ____________________________________________
Ethnicity: Country of Origin: _____________________________
Title _____________________________________________
Hispanic or Latino Origin?
1. Yes
2. No
3. Unknown
Date Form Completed _____/_____/______
5. Sex
1. Male
2. Female
6. County of Residence
9. Patient's Height _______ in
Date ____/____/____
7. Medicaid Number or N/A
10. Patient's Weight _______ lb ______ oz
Date ____/____/____
PHYSICAL ACTIVITY/INACTIVITY
11. ACTIVITY LEVEL - Compared to others of the same age/sex,
12. EXERCISE DAYS - On how many of the past 7 days did your
is your child (are you)?
child (did you) exercise or participate in physical activity for at
01 - a lot more physically active than most
least 20 minutes that made you/your child sweat or breathe
hard?
02 - a little more physically active than most
03 - Average - same as most
01 - 1 Day
06 - 6 Days
04 - a little less physically active than most
02 - 2 Days
07 - 7 Days
05 - a lot less physically active than most
03 - 3 Days
08 - 0 Days
09 - Don’t know/not sure
04 - 4 Days
09 - Don’t know/not sure
05 - 5 Days
13. TV WEEKDAY - How many hours of television does your
14. TV WEEKEND - How many hours of television does your
child (do you) watch on the typical school day (week day)?
child (do you) usually watch on the typical weekend day?
01 - 1 hour or less
05 - 5 hours
01 - 1 hour or less
05 - 5 hours
02 - 2 hours
06 - 6 hours or more
02 - 2 hours
06 - 6 hours or more
03 - 3 hours
08 - None
03 - 3 hours
08 - None
04 - 4 hours
09 - Don’t know/not sure
04 - 4 hours
09 - Don’t know/not sure
SWEETENED BEVERAGES
15. SODA TIMES - On a typical
16. SWEETENED BEVERAGE TIMES - On a
17. SODA AMOUNT - How much soda or other
day, how many times does
typical day, how many times does your child
sweetened beverage does your child (do you)
your child (do you) drink
(do you) drink sweetened beverages such as
typically drink each time?
soda? Do not count “diet”
sweet tea, punch, kool aid, sports drinks or fruit
01 - Small glass (4-6 ounces)
soda.
drinks? Do not count 100% fruit juices.
02 - Medium glass (8-12 ounces)
01 - 1 time
01 – 1 time
03 - Large glass (16 - 20+ ounces)
02 - 2 times
02 - 2 times
04 - 1 can (12 ounces)
03 - 3 or more times
03 - 3 or more times
05 - 1 bottle (16 - 20 ounces)
08 - None
08 - None
08 - Don't typically drink soft drinks or soda
09 - Don’t know/not sure
09 - Don’t know/not sure
09 - Don’t know/not sure
FAST FOOD FREQUENCY
FAT SNACK INTAKE
18. FAST FOOD - How many times a week does your child (do
19. CHIPS - On a typical day, how many times does your child
you) eat food from a fast food restaurant like Burger King,
(do you) eat French fries or chips? Chips are potato chips,
Chick-Fil-A, Bojangles, or Pizza Hut?
tortilla chips, cheetos, corn chips or other snack chips.
00 - Less than once a week
05 - More than 5 times a
01 - 1 time
08 - None
01 - Once a week
week
02 - 2 times
09 - Don’t know/not sure
02 - 2 times a week
03 - 3 or more times
09 - Don’t know/not sure
03 - 3 to 5 times a week
LOW FAT DAIRY INTAKE
20. MILK AMOUNT - On a typical day, how many glasses of milk
21. MILK TYPE - What type of milk does your child (do you)
does your child (do you) drink? (A glass is the amount in a
usually drink?
small carton at school or an 8 ounce drinking glass.)
00 - <1 glass
04 - 4 or more
01 - Skim or non-fat
05 - Flavored lowfat or skim
01 - 1 glass
08 - None
02 - Lowfat (1/2 - 1%)
06 - Flavored 2% or whole
02 - 2 glasses
09 - Don’t know/not sure
03 - Reduced fat (2%)
09 - Don’t know/not sure
03 - 3 glasses
04 - Whole
FRUIT AND VEGETABLE INTAKE
22. VEGETABLES - On a typical day, how many servings of
23. FRUITS - On a typical day, how many servings of fruit does
vegetables does your child (do you) eat? Do not include french
your child (do you) eat?
fries.
01 - 1 serving
08 - None
01 - 1 serving
08 – None
02 - 2 serving
09 - Don’t know/not sure
02 - 2 serving
09 - Don’t know/not sure
03 - 3 or more servings
03 - 3 or more servings
DHHS 4062 (07/2004) (rev 07/2005)
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