Fit and Healthy Families

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* 1. Names and Ages

Adult:

Child:

Additional:

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* 2. How many physical activities does your child(ren) do in a week (at least 30 minutes)

1-2

3-4

5-6

Other 0r additional comment

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* 3. About how many times in the average week do you engage in 30 minutes of strenuous activity (i.e. running or jogging)?

5 or more

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* 4. About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?

5 or more

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* 5. In a typical week, how much time do you and your child(ren) spend using your phone, gadgets or watching TV?

Hours (adult)

Minutes (adult)

Hours (child)

Minutes (child)

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* 6. Are you confident in motivating your child(ren) to exercise?

Extremely confident

Very confident

Somewhat confident

Not so confident

Not at all confident

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* 7. Do you regularly exercise together as a family?

Always

Usually

Sometimes

Rarely

Never

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* 8. How much do you and your children enjoying physical activity?

Always

Usually

Sometimes

Rarely

Never

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* 9. Do you and your children eat a well balance diet?

Yes

Not Sure

Other (please specify)

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* 10. Do you and your child(ren) eat 5 portions of fruit/vegetables a day?

Yes

Other (please specify)