 PERSONAL INFORMATION  The next 3 questions ask about your

How old are you? height, weight, and going hungry.

3. ON THE ANSWER SHEET, WRITE YOUR
18 Years old HEIGHT IN THE SHADED BOXES AT THE TOP
19 Years old OF THE GRID THEN FILL IN THE OVAL
BELOW EACH NUMBER.
20 Years old

21 Years old Example

Height (cm) Height (cm)
22 Years old or older
1 5 3
Write your age
1 1 1 1 1 1

What is your sex? 2 2 2 2 2 2

3 3 3 3
Male
4 4 4 4
Female
5 5 5 5

 THE QUESTIONNAIRE WILL BE STARTED AT THE 6 6 6 6

END THE ANSWERS WILL BE ADDED AND THE
RESULTS WILL BE GIVEN. 7 7 7 7
1. During the past 30 days, on how many days
8 8 8 8
did you have at least one drink containing
9 9 9 9
alcohol? I do not I do not
know know
0 DAYS

1 OR 2 DAYS

3 TO 5 DAYS

6 TO 9 DAYS
10 O 19 DAYS
2. During the past 30 days, on the days you
drank alcohol, how many drinks did you
usually drink per day?

did not drink alcohol during the past 30 days

Less than one drink
1 drink
2 drinks
3 drinks
4 drinks
5 or more drinks
 4. How much do you weigh without your shoes on? ON 7. During the past 30 days, how many times per
THE ANSWER SHEET, WRITE YOUR WEIGHT IN THE day did you usually eat vegetables?
SHADED BOXES AT THE TOP OF THE GRID. THEN FILL IN
THE OVAL BELOW EACH NUMBER did not eat vegetable during the past 30 days
Example Less than one time per day.
Weight (kg) Weight (kg) time per day
2 times per day
3 times per day
1 1 1 1 1 1 4 times per day
5 or more times per day
2 2 2 2 2 2

3 3 3 3 8. During the past 30 days, how many times per

day did you usually drink carbonated soft
4 4 4 4
drinks?
5 5 5 5 did not eat vegetable during the past 30 days
Less than one time per day.
6 6 6 6
time per day
7 7 7 7 2 times per day
3 times per day
8 8 8 8
4 times per day
9 9 9 9 5 or more times per day
I do not I do not
know know
9. During the past 7 days, on how many days did
you eat food from a fast food restaurant?
5. During the past 30 days, how often did you go
hungry because there was not enough food in 0 days
your home?
1 day
Never
2 days
Rarely

Sometimes 3 days

Most of the time 4 days

Always 5 days
6. During the past 30 days, how many times per
6 days
day did you usually eat fruit?

did not eat fruit during the past 30 days 7 days

Less than one time per day

time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

10. During the past 30 days, how many times per 14. During the past 7 days, on how many days were
day did you usually clean or brush your teeth? you physically active for a total of at least 60
I did not clean or brush my teeth during the minutes per day? ADD UP ALL THE TIME YOU
past 30 days SPENT IN ANY KIND OF PHYSICAL ACTIVITY
EACH DAY.
Less than 1 time per day
0 days
1 time per day 1 day
2 times per day 2 days
3 days
3 times per day
4 days
4 or more times per day 5 days
11. During the past 30 days, how often did you 6 days
wash your hands before eating? 7 days
Never 15. During the past 7 days, on how many days did
you walk or ride a bicycle to or from school?
Rarely
Sometimes
0 days
Most of the time
1 day
Always
2 days

12. During the past 30 days, how often did you 3 days
wash your hands after using the toilet or 4 days
latrine? 5 days
Never 6 days
Rarely 7 days
Sometimes 16. How much time do you spend during a typical
Most of the time or usual day sitting and watching television,
playing computer games, talking with friends, or
Always
doing other sitting activities?

13. During the past 30 days, how often did you use 1 to 2 hours per day
soap when washing your hands?
Never 3 to 4 hours per day
Rarely 5 to 6 hours per day
Sometimes
Most of the time 7 to 8 hours per day

Always More than 8 hours per day