Pre-program parents
survey

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Child

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Survey Form

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Program Code

This form should be completed by the participating child’s parent or carer.
Answer all items as best you can even if you are not absolutely certain. Please give your answers on the basis of your child’s behaviour over the last 6 months.

Considerate of other peoples feelings*

Restless, overactive, cannot sit still for long*

Often complains of headaches, stomachaches or sickness*

Shares readily with other children (treats, toys, pencils etc)*

Often has temper tantrums or hot tempers*

Rather solitary, tends to play alone*

Generally obedient, usually does what adults request*

Many worries, often seems worried*

Helpful if someone is hurt, upset or feeling ill*

Constantly fidgeting or squirming*

Has at least one good friend*

Often fights with other children or bullies them*

Often unhappy, downhearted or tearful*

Generally liked by other children*

Easily distracted, concentration wanders*

Nervous or clingy in new situations, easily loses confidence*

Kind to younger children*

Often lies or cheats*

Picked on or bullied by other children*

Often volunteers to help others (parents, teachers, other children)*

Thinks things out before acting*

Steals from home, school or elsewhere*

Gets on better with adults than other children*

Many fears easily scared*

Sees tasks through to the end, good attention span*

Parent questionnarie - part 2

This form should be completed by the participating child’s parent or carer. It will help us if you answer all items as best you can even if you are not absolutely certain.

1. What things (if any) have you tried in the past month to address your child’s weight?*

2. Please select the response that indicates how much you disagree or agree with the following statements:

My food preferences and eating habits influence my child’s food preferences and eating habits*

The amount of physical activity I do influences how much physical activity my child does*

The amount of time I spend being sedentary (e.g. watching TV or using the computer for entertainment) influences how much time my child spends being sedentary*

Establishing healthy behaviours (e.g. healthy eating and physical activity) early in my child’s life can predict their healthy behaviours later in life (i.e. into adulthood)*

3. Please list as many of the five main food groups that you know health experts recommend children should eat every day:

1.*

2.*

3.*

4.*

5.*

4. Please fill in the gaps in the following sentences:

a) According to health experts, children should be doing at least *

Please enter a number from 1 to 99.

minutes of physical activity

Please enter a number from 1 to 7.

days of the week.

b) According to health experts, children should spend no more than*

Please enter a number from 1 to 24.

hours a day using electronic media for entertainment (e.g. watching TV, playing video games) outside of school time.

5. Please select the response that best describes how confident you feel in response to the following statements

I can make improvements to my child’s/family’s eating habits and maintain them*

I can increase the amount of time my child spends being physically active and maintain it*

I can reduce the amount of time my child spends being sedentary e.g. watching TV, playing computer games for entertainment*

Pre-program parentssurvey

Pre-program parents
survey