Pre-Self Reporting Health Questionnaire
This questionnaire is designed to track the progress of participants in Hays County Food Bank's Child Nutrition Engagement Program and Senior Nutrition & Wellness Program. This is not a mandatory quiz; however, qualifying participants will receive a small gift to show our gratitude.
In order to qualify, participants must submit both the pre and post-test and have at least 80% participation in the program (attend 10/12 classes).
Qualifying participants will receive a $10 gift card to a local grocer.

**En Español:
Este questionario es diseñado para seguir el progreso de los participantes en Hays County Food Banks Child Nutrition Engagement Program And Senior Nutrition Wellness Program (Programa de Nutrición Para Niños y Personas de La Tercera Edad). Este questionario nos es obligatorio. Mas sin embargo, los participantes que califiquen recibirán un pequeño obsequio como agradecimiento.
Par poder calificar, los participantes deben someter el examen posterior y anterior y tener un 80% de participación en el programa (asistir de 10 a 12 classes).
Participantes calificantes recibirán una tarjeta de $10 para una tienda local.

Name *
**Nombre
Your answer
Contact Information (Phone Number or Email) *
**Información para contacto (Numero de Teléfono o Correo Electrónico)
Your answer
Age *
**Edad
Your answer
Gender *
**Sexo
Height *
**Estatura
Your answer
Weight *
**Peso
Your answer
Race/Ethnicity (Select all that apply) *
**Etnicidad/Raza (Marque todos los que apliquen)
Required
On average, how have you felt in the past 7 days? (Select all that apply on a regular basis) *
**Como promedio, Como se ha sentido en los últimos 7 días? (Marque todos los que apliquen regularmente)
Required
Are you or your children receiving assistance from a government program for food assistance? *
**Esta usted o sus hijos recibiendo ayuda alimentaria de parte del gobierno?
Required
Are you or your children receiving assistance from a government program for health insurance? *
**Esta usted o sus hijos recibiendo asistencia de aseguranza medica de parte de algún programa del gobierno?
Do you have access to clean running water? *
**Tiene usted acceso a agua potable?
How many hours of sleep do you get a night? *
**Aproximadamente cuanta horas duerme cada noche?
How many hours a day do you spend using electronics (TV, Social Media, Phones, Video Games)? *
**Cuantas horas por día pasa usted usando aparatos electrónicos (TV, Redes Sociales, Teléfono, Juegos de Video)?
Does anyone in your household smoke? *
**Alguien en su hogar fuma?
If 1 or more persons in the household smokes, do they smoke inside the home? *
**Si mas de una persona en su hogar fuma. Fuman dentro o fuera de la casa?
Do you or anyone in your family have a history of any of the following conditions? (Select all that apply) *
**Usted u otro de su familia tiene un historial de una de las siguientes? (Marque todos los que apliquen)
Required
Have you been diagnosed with arthritis? *
**Ha sido usted diagnosticado de artritis?
Have you been diagnosed with depression? *
**Ha sido usted diagnosticado de depression?
How many meals do you eat a day? *
**Cuantas veces al día ingiere usted alimentos?
How much fruit and/or vegetables do you eat with each meal? *
**Aproximadamente cuanta fruta o vegetales ingiere usted con cada alimento?
Do you drink beverages with your meals? *
**Bebe usted cuando ingiere alimentos?
If you selected yes or sometimes, what type of beverage(s) do you drink with your meals? (Check all that apply) *
**Si usted selecciono si o algunas veces, que tipo de bebidas consume cuando ingiere alimentos? (Marque todos los que apliquen)
Required
Which vegetables have you tried? (Check all that apply) *
**Que vegetales ha probado? (Marque todos los que apliquen)
Required
Which fruits have you tried? (Check all that apply) *
**Que fruta ha probado? (Marque todos los que apliquen)
Required
How often do you "snack" each day? *
**Con que frecuencia botana al día?
What do you usually choose as a snack? (Check all that apply) *
**Generalmente, que opciones tiene como botanas? (Marque todos los que apliquen)
Required
On a scale from 1-10 how much energy would you have throughout the day? *
**En la escala del 1 al 10. Cuanta energía tiene al día?
Least amount
Most amount
Do you have access to a recreational park and/or facility (gym, track, city park)? *
**Tiene accesos a un parquet recreacional o un gimnasio?
Have you participated in physical activity for at least 30 minutes a day for the past 90 days? *
**A participado en una actividad física de por lo menos 30 minutos por día en los últimos 90 días?
How many hours are you physically active in a week? *
Aproximadamente cuantas horas a la semana esta usted activo/a?
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