EARLY TEEN QUESTIONNAIRE - Harvard Medical School · PDF fileEARLY TEEN QUESTIONNAIRE ... cheese, butter, ice cream) Less than once per week ... B.11. Margarine (stick-type not tub)

Project Viva (CQ12-F)

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EARLY TEEN QUESTIONNAIRE

Thank you for continuing to help us learn how kids and teenagers grow up! This year’s survey is a little

bit longer than last year’s, but has a lot of the same questions you have seen before. Just like last year,

please read each question, mark your answers, and return the survey to us. Remember, you don’t

have to answer any question that you don’t want to.

SECTION A. QUESTIONS ABOUT YOUR EATING HABITS A.1. How many days per week (including weekdays and weekends) do you eat breakfast?

1 Less than 1 day per week 4 5 or 6 days per week

2 1 or 2 days per week 5 Every day

3 3 or 4 days per week

A.2. Where do you get your lunch on a school day? (Please check all that apply.)

A Bring from home D Get from a store or food truck

B Get from school cafeteria E Get from a vending machine

C Get from a fast food restaurant F I don’t eat lunch on school days

A.3. How many days per week do you eat supper or dinner together with family members (“family

dinner”)?




V. 1 SA 2 IA


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A.4. How often do you eat supper or dinner while watching TV?

A.5. How often do you eat a snack while watching TV?




A.6. How often do you eat something from a fast food restaurant (like Burger King, McDonald’s,

Dunkin’ Donuts, Taco Bell, or a pizza place)?




A.7. How often do you eat something from any other restaurant?




A.8. In the past 12 months, have you ever eaten so much food in a short period of time that you would

be embarrassed if others saw you?

1 Yes (Go to A.8.a)

2 No (Go to A.9.)




a) During the times when you ate this way, did

you feel out of control, like you couldn’t stop

eating even if you wanted to stop?

1 Yes

2 No


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A.9. Imagine you are eating a meal or snack at home or at a restaurant. Imagine that you have

eaten enough so you are no longer hungry. How often would you keep eating?

1 Never 2 Rarely 3 Sometimes 4 Often 5 Always

A.10. Imagine you ate a meal or snack a little while ago and are not hungry anymore. How often

would you start eating again?

SECTION B. QUESTIONS ABOUT WHAT YOU DRINK AND EAT

B.1. In the past month, how often did you

drink a can, bottle, or glass of …

Less than

once per

week

Once

per

week

2-4 times

per week

Nearly

daily or

daily

Twice or

more per

day

a. Soda, such as Coke, Pepsi or Sprite? 1 2 3 4 5

b. Diet soda, such as Diet Coke, Diet

Pepsi or Sprite Zero? 1 2 3 4 5

c. Sports drink, such as Gatorade or

PowerAde? 1 2 3 4 5

d. Low-calorie sports drink, such as

Propel or G2? 1 2 3 4 5

e. Energy drink, such as Red Bull or Jolt? 1 2 3 4 5

f. 100% fruit juice, such as orange juice,

apple juice, or grape juice? 1 2 3 4 5

g. Fruit drinks, lemonade, Snapple, Sunny

Delight, sweetened tea or coffee

drinks? 1 2 3 4 5

h. White milk? 1 2 3 4 5

i. Chocolate or other flavored milk? 1 2 3 4 5

j. Plain water? (Tap and bottled) 1 2 3 4 5



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For each question below, mark how often you have eaten the food or foods during the past month.

Remember to include things you eat at home and at school. Not all of the foods you eat are listed in the

questions below.

B.2. Dark Green Leafy Vegetables (like spinach,

romaine lettuce, kale, turnip greens, bok

choy)

1 Less than once per week

2 Once per week

3 2-4 times per week

4 Nearly daily or daily

5 Twice or more per day

B.7. Other Fruits (like fresh apples or pears,

bananas, berries, grapes, melons)


2 Once per week




B.3. Broccoli, Cauliflower, Cabbage, Brussel

Sprouts


2 Once per week




B.8. Whole Milk Dairy Foods (whole milk, hard

cheese, butter, ice cream)


2 Once per week




B.4. Carrots


2 Once per week




B.9. Low-fat Milk Products (like low-fat/skim

milk, yogurt, cottage cheese)


2 Once per week




B.5. Other Vegetables (like peas, corn, green

beans, tomatoes, squash)


2 Once per week




B.10. Whole eggs


2 Once per week




B.6. Citrus Fruits (like oranges, grapefruits, orange

juice or grapefruit juice,)


2 Once per week




B.11. Margarine (stick-type not tub)


2 Once per week





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Remember to answer how often you have eaten the food or foods listed in the past month.

B.12. Whole Grain Foods (like whole grain breads,

brown rice, whole wheat pasta)


2 Once per week




B.16. Processed Meats (sausages, salami,

bologna, hot dogs, bacon)


2 Once per week




B.13. Pasta, Rice, Noodles


2 Once per week




B.17. Fish/Seafood (not fried, but broiled,

baked, poached, canned)


2 Once per week




B.14. Baked Products (donuts, cookies,

muffins, crackers, cakes, sweet rolls,

pastries)


2 Once per week




B.18. Deep Fried Foods (deep fried chicken,

fish or seafood; French fries, onion rings)


2 Once per week




B.15. Beef, Pork or Lamb as Main Dish


2 Once per week




B.19. How often do you add salt to food at the

table?


2 Once per week




B. 20 Do you currently take a multivitamin?

1 Yes (Go to B.20.a)

2 No (Go to Section C.)

a. How many days per week?

______ days per week


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SECTION C. QUESTIONS ABOUT HOW YOU FEEL C.1. In the past year, how often do you:

a. Feel hopeful about the future

b. Notice you didn’t have as much energy as you usually do

c. Feel “down in the dumps” or depressed

d. Feel worthless

e. Have trouble concentrating

f. Have trouble enjoying activities you usually enjoy

If you are having these problems, please talk to a parent, teacher or other trusted adult.

SECTION D. QUESTIONS ABOUT YOUR PERSONALITY

For each item, mark whether it is “Not True”, “Somewhat True”, or “Certainly True” for you.

D.1. Not True Somewhat

True

Certainly

True

a. I try to be nice to other people. I care about

their feelings. 1 2 3

b. I am restless. I cannot sit still for long. 1 2 3

c. I get a lot of headaches, stomach aches

or sickness. 1 2 3

d. I usually share with others, for example, music,

games or food. 1 2 3

e. I get very angry and often lose my temper. 1 2 3

f. I would rather be alone than with people of my

own age. 1 2 3

g. I usually do as I am told. 1 2 3








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Remember, for each item, mark whether it is “Not True”, “Somewhat True”, or “Certainly True” for you.


True

Certainly

True

a. I am kind to younger children. 1 2 3

b. I am often accused of lying or cheating. 1 2 3

c. Other children or young people pick on me or

bully me. 1 2 3

d. I often offer to help others (parents,

teachers, children). 1 2 3

e. I think before I do things. 1 2 3

f. I take things that are not mine from home, school

or elsewhere. 1 2 3

g. I get along better with adults than with people my

own age. 1 2 3

h. I have many fears; I am easily scared. 1 2 3

i. I finish the work I am doing. My attention is good. 1 2 3


True

Certainly

True

a. I worry a lot. 1 2 3

b. I am helpful if someone is hurt, upset or feeling ill. 1 2 3

c. I am constantly fidgeting or squirming. 1 2 3

d. I have one good friend or more. 1 2 3

e. I fight a lot. I can make other people do what

I want. 1 2 3

f. I am often unhappy, depressed, or tearful. 1 2 3

g. Other people my age generally like me. 1 2 3

h. I am easily distracted; I find it difficult

to concentrate. 1 2 3

i. I am nervous in new situations. I easily

lose confidence. 1 2 3


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SECTION E. QUESTIONS ABOUT YOUR BODY Remember, there are no right or wrong answers. We just want to know what you think.

E.1. Are you currently:

1 Not trying to do anything about your weight 3 Trying to stay the same weight

2 Trying to gain weight 4 Trying to lose weight

E.2. In the past year, how happy have you been with the way your body looks?

1 Totally 2 Pretty Much 3 A Little 4 Not at all

E.3. In the past year, have you done any of the following things to lose weight or keep from gaining

weight?

a. Exercise more 1Yes 2 No e. Go on a diet 1Yes 2 No

b. Eat more fruits or vegetables 1Yes 2 No f. Skip a meal 1Yes 2 No

c. Not eat for a day or more 1Yes 2 No g. Eat fewer sweets 1Yes 2 No

d. Eat smaller portions 1Yes 2 No h. Anything else 1Yes 2 No

h.1. If yes, please tell us what:___________________

E.4.

Girls go through normal changes as they get

older. Please LOOK at the drawings and READ

the sentences below each of them. Then

choose the drawing closest to your stage of

hair development.

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

THIS IS KINDA

EMBARRASSING!

There is no

There is no

pubic hair.

There is a little,

long, lightly

colored hair.

The hair may be

straight or a little

curly.

The hair is darker,

coarser, and

more curled.

It has spread out

and thinly covers

a larger area.

The hair is now as

dark, curly, and

coarse as that of a

grown woman.

The hair has not

spread out to the

legs.

The hair is now like

that of a grown

woman.

The hair often

forms a triangle

(▼) as it spreads

out to the legs.


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SECTION F. QUESTIONS ABOUT FAMILY AND FRIENDS F.1. Do your parents know what you do during your free time?

F.2. Do your parents know the friends you hang out with during your free time?

My parents…

1 Know none of my friends

2 Know a couple of my friends

3 Know most of my friends

4 Know all of my friends

F.3. In the past year, how often have the following people made a comment about your weight…

Never Rarely Sometimes Often Always

a. Your teacher or coach? 1 2 3 4 5

b. Boys? 1 2 3 4 5

c. Other girls? 1 2 3 4 5

Never Rarely Sometimes Often Always

Doesn’t

apply to me

d. Your brother(s) or sister(s)? 1 2 3 4 5 9

e. Your father? 1 2 3 4 5 9

f. Your mother? 1 2 3 4 5 9

F.4. How often do other kids …

a. Pick on you?

b. Say mean things to you in person?

c. Say mean things to you online or by text message?

d. Say bad things about you to other kids in person?

e. Say bad things about you to other kids online or by text message?

f. Punch, kick or shove you?

g. Wreck your things?

If you are having these problems, please talk to a parent, teacher or other trusted adult.










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SECTION G. QUESTIONS ABOUT SLEEPING

G.1. Imagine: School is canceled! You can get up whenever you want to. When would you get out of

bed? Between…

G.2. Is it easy for you to get up in the morning?

G.3. When do you have the most energy to do your favorite things?

G.4. When does your body start to tell you it’s time to go to bed (even if you ignore it)? Between…

G.5. Guess what? Your parents have decided to let you set your own bedtime. What time would you

pick? Between…

G.6. How often are you tired and grumpy during the day?

G.7. Are you usually alert most of the day?

1 5:00 and 6:30 am 4 9:45 and 11:00 am

2 6:30 and 7:45 am 5 After 11:00 am

3 7:45 and 9:45 am

1 No way! 3 Pretty easy

2 Sort of 4 It’s a cinch

1 Morning! I’m tired in the evening 3 Evening more than morning

2 Morning more than evening 4 Evening! I’m tired in the morning

1 8:00 and 9:00 pm 4 12:30 and 1:45 am

2 9:00 and 10:15 pm 5 1:45 and 3:00 am

3 10:15 pm and 12:30 am

1 8:00 and 9:00 pm 4 12:30 and 1:45 am

2 9:00 and 10:15 pm 5 1:45 and 3:00 am

3 10:15 pm and 12:30 am




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G.8. How often do you…

a. Need someone to wake you up in the morning?

b. Fall back to sleep after being woken up in the morning?

c. Have trouble getting out of bed in the morning?

d. Think that you need more sleep?

e. Fall asleep or get drowsy during class periods?

f. Get sleepy or drowsy while doing your homework?

SECTION H. QUESTIONS ABOUT YOUR ACTIVITIES H.1. Have you ever tried or experimented with cigarette smoking, even a few puffs?

1 Yes (Go to H.1.a)

2 No (Go to H.2.)

H.2. Have you ever tried drinking alcohol (beer, wine or liquor), even a few sips?

1 Yes (Answer H.2.a)

2 No (Go to H.3)







a) On average, in the past year, how often did you drink beer, wine

or liquor?

1 Never in the past year 4 1-2 days per week

2 Less than once a month 5 3-5 days per week

3 Less than once a week 6 Almost every day or every day

a) On average, in the past year, how often did you smoke a

cigarette?

1 Never in the past year 4 1-2 days per week

2 Less than once a month 5 3-5 days per week

3 Less than once a week 6 Almost every day or

every day


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H.3. What time does your school day usually start? ___ :___ ___ am

H.4. In school, how many days per week do you have gym or PE (phys ed)?



H.5. How many hours per day do you spend watching TV shows, not including DVDs or videos?

Include TV shows you watch on a TV, computer, or handheld device like an iPod, iPad, or iPhone.

(Check one box for school days and one for weekend days.)

a. a. On a school day?

1 None

2 Less than 1 hour a day

3 1 to less than 2 hours a day

4 2 or 3 hours a day

5 4, 5 or 6 hours a day

6 7 or more hours a day

b. On a weekend day?

1 None

2 Less than 1 hour a day

3 1 to less than 2 hours a day

4 2 or 3 hours a day

5 4, 5 or 6 hours a day

6 7 or more hours a day

Thank You!!!

Documents

EARLY TEEN QUESTIONNAIRE - Harvard Medical School · PDF fileEARLY TEEN QUESTIONNAIRE ... cheese, butter, ice cream) Less than once per week ... B.11. Margarine (stick-type not tub)