For Practicum: Food, Nutrition & Fitness

Lifestyle Behaviors
1. How many times did you exercise this week?

None

1-3 times

4 or more

2. About how long did you exercise each time?

0- 10 minutes

10-20 minutes

20-30 minutes

30 minutes or more

3. What kinds of exercise/physical activity do participate in?

Walking/swimming/biking/jogging/dancing

Resistance bands/weights/sit ups/push-ups/squats

Yoga/stretching

Other

4. How many fruits did you eat yesterday?________________________________________________

5. Is this how much you usually eat on any given day?

Yes

No

Unsure

6. How many vegetables did you eat yesterday?____________________________________________

7. Is this how much you usually eat on any given day?

Pre-Assessment

Yes

No

Unsure

8. How many times did you cook a meal at home this week?

None

1-2 days

3-4 days

5-7 days

9. How many times did you use oil instead of butter, grease or lard when cooking this week?

None

1-2 days

3-4 days

5-7 days

10. How often did you use the Plate Method during a meal this week?

None/Unsure

1-2 days

3-4 days

5-7 days

11. How often did you watch how much food you ate in the past week?

None

Some of the time

Most of the time

Every time

12. How often did you make a healthier choice when grocery shopping this week?
Pre-Assessment

None

Some of the time

Most of the time

Every time

13. How often did you read a label when deciding what to buy at the store this week?

None

Some of the time

Most of the time

Every time

14. How often did you choose a healthier snack this week?

None

A few times

Most of the time

Every time

15. How many times did you buy food this week for a meal? (Restaurants, take-out, etc.)

None/Unsure

1-2 days

3-4 days

5-7 days

16. How many sugary drinks did you drink yesterday?____________________________________________

17. Is this how much you usually eat on any given day?

Yes

No

Pre-Assessment

Unsure

18. How many times did you eat fried foods this week?

None/Unsure

1-2 days

3-4 days

5-7 days

Nutrition and Physical Activity Knowledge Assessment

1.

Eating healthy and being active can contribute to the following:

Lose weight

Reduce risk for chronic disease (diabetes, high blood pressure, obesity, etc.)

Increase energy

Reduce need for so many medicines

All of the above

2. Physical activity is good for:

Keeping blood sugar in a healthy range

Losing weight

Better sleep

Stress relief

All of the above

3. Which of the following are ways to be active?

Walk in place while watching TV

Take the stairs instead of an elevator

Garden

Pre-Assessment

Dance

All of the above

4. What goes in the largest portion of a Healthy Plate?

Protein

Carbohydrates

Nonstarchy vegetables

Fruit

5. Which one of the following is a nonstarchy vegetable?

Corn

Spinach

Potato

Beans

6. If a nutrition label says there are 100 calories in a serving and you eat 2 servings, how many calories did
you eat?

100

200

150

300

7. High blood pressure can increase your risk for

Heart attack

Kidney disease

Eye disease

All of the above

8. Which of the following foods are high in sodium?

Pre-Assessment

Lunch/deli meat
5

Instant cup noodles

Ketchup

Canned soup

All of the above

9. Which of the following can cause stress?

Moving

Getting a promotion at work

Having a baby

Losing a job

All of the above

Patient Satisfaction: Post-Assessment Only

Please mark on the scale, how much you agree with the following statements.
1. I enjoyed being a part of this class.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

2. I feel better because of this class.

Strongly Disagree

Disagree

Neutral

Agree

Pre-Assessment

Strongly Agree

3. I feel supported in this class

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

4. I plan to continue to talk to the people I met in this class.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. I plan to maintain the healthy changes Ive made because of this class

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

6. What topics discussed in class did you find the most helpful?
7. What topics discussed in class did you not find helpful?
8. Would you recommend this class to a family member or friend?

Yes

No

Pre-Assessment

Unsure

9. Would you attend this class again?

Yes

No

Unsure

Pre-Assessment