5-2-1-0 Healthy Habits Questionnaire
Well-Child Check Visits (Ages 2-18)
Please take a few moments to answer the following questions. Your healthcare provider will
review your answers during you/your child’s visit. The questions below will help us discuss
ways to make small changes to improve you/your child’s health.
Today’s
Patient Name:______________________________DOB:________________Date:_________
1. How many servings of fruits or vegetables do you eat a day?
__________
2. How many times a week do you eat dinner at the table as a family?
__________
3. How many times a week do you eat breakfast?
__________
4. How many times a week do you eat takeout or fast food?
__________
5. How many hours a day do you watch TV/movies or sit
__________
and play video/computer games?
6. Do you have a TV in the room where you sleep?
YES / NO
7. Do you have a computer in the room where you sleep?
YES / NO
8. How much time each day do you spend in active play?
__________
(Faster breathing/heart rate or sweating)
9. How many 8-ounce servings of the following do you drink a day?
____ 100% juice
_____ Fruit or sports drinks
_____Soda or punch
____ Water
_____ Whole milk or 2%
_____ Milk Nonfat (skim), low-fat
(1%)
Based on you answers, is there ONE thing you would like to change now?
__Eat more fruits and vegetables.
___Play outside more often.
___Eat less fast food/takeout.
___Drink less soda, juice or punch.
___Take the TV out of the bedroom
___Switch to nonfat (skim) or low-fat (1%) milk.
___Drink more water.
___Spend less time watching TV/movies and
playing video/computer games.