Student Nutrition and Wellness Survey
Help us understand your nutrition and wellness habits. Your responses are confidential and will be used to improve student health programs.
Full Name
*
First Name
Last Name
Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
How many meals do you typically eat each day?
*
1 meal
2 meals
3 meals
More than 3 meals
How often do you eat breakfast?
*
Every day
Most days
Sometimes
Rarely/Never
Which of the following foods do you eat most often? (Select all that apply)
*
Fruits
Vegetables
Whole grains
Dairy products
Meat or protein foods
Snacks (chips, candy, etc.)
Fast food
Other
How many cups of water do you drink on a typical day?
*
Less than 2 cups
2-4 cups
5-7 cups
8 or more cups
How often do you participate in physical activity (such as sports, exercise, or active play)?
*
Every day
3-5 times a week
1-2 times a week
Rarely/Never
Please rate your agreement with the following statements about your nutrition and wellness:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have access to healthy food at home
1
2
3
4
5
I have access to healthy food at school
6
7
8
9
10
I feel I make healthy food choices
11
12
13
14
15
I am physically active enough to stay healthy
16
17
18
19
20
I know where to find reliable nutrition information
21
22
23
24
25
How would you rate your overall wellness?
*
1
2
3
4
5
What are the biggest challenges you face in maintaining good nutrition and wellness? (Select all that apply)
*
Lack of time
Cost of healthy foods
Limited access to healthy foods
Lack of knowledge
Preference for unhealthy foods
Lack of motivation
Other
Where do you usually get your information about nutrition and wellness?
*
Family
Friends
Teachers
School programs
Internet/social media
Healthcare professionals
Other
Is there anything else you would like to share about your nutrition or wellness?
Submit Survey
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