Overweight & Obesity

MCH Focus Group on Overweight and Obesity in Children, Adolescents, and Women

Please answer the following questions pertaining to you or your child's eating habits and activity level.

You may complete the survey once for each family member living at home. You; your spouse; children; other family members living within your home.

Sex	Male Female

Age

How often do you eat out?

1 time/week

2-3 times/week

> 3 times/week

Seldom/Never

Time spent on computer daily

1 hour

2-3 Hours

>3 hours

None

Time spent watching TV daily

1 hour

2-3 hours

>3 hours

None

Time spent playing video games daily

1 hour

2-3 hours

>3 hours

None

Do you exercise regularly?

Yes, 1-2 times/week for 30 minutes

Yes, 1-2 times/week for >30 minutes

Yes, 3-5 times/week for 30 minutes

Yes, 3-5 times/week for >30 minutes

Yes, more than 6 times/week

I have no regular exercise program

Eating habits and Exercise routine

I am eating healthy & exercising

I am NOT eating healthy/exercising

Eating healthy; not enough exercise

Enough exercise; not eating healthy

I am not sure.

Do you feel that your are:

A normal weight for my height.

Somewhat overweight for my height.

Obese.

Underweight for my height.

Not sure what is normal for me.

Thank you for taking our survey. St.Francois County Health Center