I
work on the computer, watch television and play video games less than
2 hours every day (Yes/No)
I exercise every day (sports, walking,
bicycling) (Yes/No)
I walk to the bus stop when possible,
instead of asking for a ride (Yes/No)
I do not use illegal drugs (Yes/No)
I do not drink alcohol (Yes/No)
I play outside every day the weather
permits (Yes/No)
I eat 2-4 fruits every day (Yes/No)
I eat 3-5 vegetables every day (Yes/No)
I choose to eat healthy food instead
of junk food when I get to choose my meal (Yes/No)
I eat out less than 3 times per week
(Yes/No)
I do not take any kind of medication
without asking a parent first (Yes/No)
I take the correct dosage of medication
when I need it (Yes/No)
I wash my hands after I use the bathroom
(Yes/No)
I wash my hands before I eat (Yes/No)
I stay home from school when I
have a fever or if I am contagious (Yes/No)
I brush my teeth at least twice a
day (Yes/No)
I don’t share brushes or combs
with anyone (Yes/No)
When I sneeze, I cover my mouth
to keep from spreading germs (Yes/No)
For additional health information
visit: