Prepared by Melissa Knudson, R.D.

INSTRUCTIONS TO CHILD AND PARENTS:

1. DISTRIBUTE PRETEST END OF WEEK 1-FEBRUARY 23RD

2. PARTICIPANTS COMPLETE BETWEEN WEEK 1 AND 2

3. COLLECT START  OF WEEK 2-MARCH 2

4. CHILD AND PARENT SHOULD DO HOMEWORK TOGETHER IF POSSIBLE

NAME-

DATE OF BIRTH -

SCHOOL-OAKLAND/UPTON/OTHER-

WEEK 2 (NUTRITION)

1. Breakfast is the most important meal of the day.  This week, how many days did you eat breakfast?

1. 1-3x
2. 3-5x
3. 5-7x

2. It is recommended to eat at least five servings of fruits and vegetables per day.  A serving is one piece or 1 cup fresh or cup cooked.  On average this week, how many servings of fruits and vegetables did you have per day?

1. 0-2
2. 2-4
3. 5 or more

3. Families that eat dinner together tend to have significantly healthier diets than those that eat alone or on the run.  This week, how many nights did your family eat dinner together around the family dinner table?

1. 0-2
2. 2-4
3. 5-7

4. People who eat based on hunger and fullness signals are generally successful at maintaining healthy body weights.  On a scale of +5 (stuffed-too full) to 5 (uncomfortably hungry), circle your usual hunger and fullness level before eating, and after completing a meal.

                   A.  Before eating:      5    -4    -3    -2    -1     0    +1    +2    +3    +4    +5

                                                (starving)                       (satisfied)                         (stuffed)

                   B.  After eating:         -5    -4    -3    -2    -1     0     +1    +2    +3    +4     +5

5. A meal should include at least three different food items, to provide variety and balance of protein, carbohydrate, and fat.  On average, how many meals per week do you have that include a protein food, a source of healthy fat, and a grain, fruit, or vegetable?  

1. 3-5 balanced meals per week
2. 6-9 balanced meals per week
3. 10-14 balanced meals per week
4. More than 14 balanced meals per week
5. I don´t know

6. Not drinking enough water can cause lack of energy and fatigue from being dehydrated.  How many glasses of water do you usually drink per day?

1. 0-1
2. 2-4
3. 5-8
4. More than 8

7. It is important to get enough calcium in the diet to promote optimal growth and strong bones.  How many servings of lowfat dairy products or calcium fortified foods do you have per day? 

1. 0-1
2. 2-3
3. 3-4
4. More than 4
5. I don´t know

PLEASE FILL OUT AND TURN IN AT THE END OF SESSION 2-MARCH 2, 2005

CHILD SIGNATURE AND INITIAL-

PARENT SIGNATURE AND INITIAL-

INSTRUCTOR SIGNATURE AND INITIAL-

SUPERVISOR SIGNATURE AND INITIAL-

TICKET GIVEN TO PARTICIPANT FOR COMPLETION-Y/N

 YOUR CHIP TEAM OF INSTRUCTORS