Appendix: Nutrition and Exercise Survey
Name _________________________
Date __________________
Nutrition and Exercise Survey
1) I feel ___________________ about who I am.
2) I feel ___________________ about how I look.
3) If I could change one thing about what I eat I would change ________.
4) My idea of a delicious dinner is ______________________________.
5) My idea of a healthy dinner is ________________________________.
6) To get exercise I __________________________________________.
7) I exercise about ___________ minutes each day.
8) I love to play _____________________________________________.
9) My favorite food to buy at the grocery store is ___________________.
Circle either healthy or unhealthy for question #10.
10) I feel like I am a healthy/unhealthy person because __________.
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