Contact Person:
Alice Blume
(765) 494-8430
Purdue University Cooperative Extension Services
School/Group:____________________
Grade level: Pre_______ Post________
Name:
1. Do you wash your hands before you eat?
___All the time
___Sometimes
___Never
2. Do you read food labels?
___All the time
___Sometimes
___Never
3. Do you help plan meals at home?
___ All the time
___Sometimes
___Never
4. How much "pop" (soft drinks, soda, cola) do you drink in a day?
___1 can
___2 cans
___3 cans or more
___None
5. What did you eat and drink before school started today?
6. What do you eat for snacks? (Check all that apply)
___Cereal, bread, popcorn
___apple, orange juice, grapes, banana, raisins
___carrots, lettuce salad, broccoli, celery
___milk, cheese, yogurt
___peanut butter, eggs, peanuts
___cookies, snack cakes, candy, pop
___donuts, potato chips, french fries
7. What are your favorite snacks?
ENTRY DATE:: January 1999
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