Health Survey on School Proximity, Physical Activity, and Healthy Food Options

1. Health 1) About how far do you live from your child/children’s Elementary School?

2. Health 2) About how far do you live from your child/children’s Junior High or Middle School?

3. Health 3) About how far do you live from your child/children’s High School?

4. Health 4) How does/do your Elementary school child/children usually get to school?

5. Health 5) How does/do your Middle or Junior High School child/children usually get to school?

6. Health 6) How does/do your High School child/children usually get to school?

7. Health 7) Are you aware of any efforts at your child’s Elementary School to provide healthier food options and increase physical activity?

8. Health 8) Which of the following would encourage your child(ren) to walk or bike to school more frequently?

9. Health 9) Are you aware of any efforts at your child’s Junior High or Middle School to provide healthier food options and increase physical activity?

10. Health 10) Are you aware of any efforts at your child’s High School to provide healthier food option and increase physical activity?

11. Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region North Coast

12. Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region North County

13. Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region San Luis Obispo

14. Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region South County

15. Health 12) Which of the following would encourage your child(ren) to do more physical activity?

16. Health 13) Do you or does anyone in your household, have a permanent physical or mental impairment that substantially limits a major life activity, such as bathing, dressing, stair climbing, shopping, or managing one’s money?

17. Health 14) Who helps that person perform these activities?

18. Health 15) Are you, or is anyone else in your household, the caregiver to…? Region North Coast

19. Health 15) Are you, or is anyone else in your household, the caregiver to…? Region North County

20. Health 15) Are you, or is anyone else in your household, the caregiver to…? Region San Luis Obispo

21. Health 15) Are you, or is anyone else in your household, the caregive to…? Region South County

22. Health 16) Does your employer try to help with healthier eating and physical activity, which might include providing stress management classes, subsidizing health club memberships, or paying for weight reduction programs?

23. Health 17) Would you say, in general, your mental health, which includes stress, depression and problems with emotions, is…

24. Health 18) Have you felt the need to discuss problems or situations with a mental health professional, but not had the money or insurance to do so?

25. Health 19) Have you felt the need to talk to a mental health professional, but were concerned others treat you differently if they found out?

26. Health 20) Do you have health insurance?

27. Health 21) Why don’t you have health insurance?

28. Health 22) Does that include insurance through:

29. Health 23) At this time, are you covered by Medicare?

30. Health 24) Does your health insurance cover…? Region North Coast

31. Health 24) Does your health insurance cover…? Region North County

32. Health 24) Does your health insurance cover…? Region San Luis Obispo

33. Health 24) Does your health insurance cover…? Region South County

34. Health 25) Do you have a regular source of health care?

35. Health 26) When you need health care, do you usually go to a…

36. Health 27) If you do not have a regular source of health care, what is the one main reason?

37. Health 28) Have you or a member of your household needed health care in the past year and been unable to receive it because you could not afford it?

38. Health 29) Do you have a regular source of dental care?

39. Health 30) How long has it been since you last visited a dentist for a routine check up?

40. Health 31) How long has it been since your child(ren) visited a dentist for a routine check up?

41. Health 32) Which of these dental activities does your child do at home?

42. Health 33) Have you completed an Advance Health Care Directive, or other legal health care document, such as a Durable Power of Attorney for Health Care, Living Will, or Health Care Proxy with the past 5 years?

43. Health 34) How many days a week do you engage in physical activity, such as brisk walking or gardening, for a combined total of 30 minutes or more?

44. Health 35) On average, do you eat 5 or more serving of fruits and vegetables every day?

45. Health 36) In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at work, at home, or at fast-food restaurants, carryout or drive through.

46. Health 37) On average, does your child eat 5 or more servings of fruit and vegetables every day?

47. Health 38) On average, does your teen eat 5 or more servings of fruit and vegetables every day?

48. Health 39) How concerned are you about helping your child to eat healthy? Would you say you are…

49. Health 40) Considering all types of alcoholic beverages, in the past 30 days, about how many times did you have (4 if female; 5 if male) or more drinks on an occasion?

50. Health 41) Do you smoke cigarettes every day, some days, or not at all?