Healthy Harford :: Creating a Better Harford Together

Please answer the following survey questions:

SECTION 1: PHYSICAL ACTIVITY

When you are at work (job, school, etc.), which of the following best describes what you do?

Mostly sitting or standing

Mostly walking

Mostly heavy labor or physical work

Please read: We want to know about two types of physical activity - mild and intense. Mild activities cause a small rise in breathing or heart rate, while intense activities cause a large rise in breathing or heart rate.

Mild - able to carry on a conversation:

Walking fast (3 miles per hour or faster, but not race walking)
Water aerobics
Bicycling 10 miles per hour or less
Tennis (doubles)
Slow dancing
General gardening

Intense - not able to say a few words without stopping for a breath

Hiking uphill or with a heavy backpack
Race walking, jogging or running
Swimming laps
Tennis (singles)
Fast dancing
Bicycling more than 10 miles per hour
Jumping rope

Now, thinking about the mild activities you do in your free time in a usual week, do you do mild activities for at least 10 minutes at a time?

Yes

Don't know / Not Sure

How many days each week do you do these mild activities for at least 10 minutes at a time?

Days per week:

Enter days per week above

Do not do any mild activities for at least 10 minutes at a time (go to question 5)

Don't know / Not sure

On days when you do mild activities for at least 10 minutes at a time, how much total time each day do you spend doing these activities?

10-15 minutes

16-30 minutes

31-45 minutes

46-60 minutes

61 or more minutes

None

Now thinking of intense activities you do in your free time in a usual week, do you do intense activities for at least 10 minutes at a time?

Yes

Don't know / Not Sure

How many days each week do you do these intense activities for at least 10 minutes at a time?

Days per week:

Enter days per week above

Do not do any intense activities for at least 10 minutes at a time (go to question 8)

Don't know / Not sure

On days when you do intense activities for at least 10 minutes at a time, how much total time each day do you spend doing these activities?

10-15 minutes

16-30 minutes

31-45 minutes

46-60 minutes

61 or more minutes

None

What stops you from being more physically active? Check all that apply.

I am physically active 5-7 days per week

I don't have enough time

Lack of access to recreation areas such as walking trails, sidewalks, biking paths, etc.

Lack of support from family and friends

I keep putting it off

I have physical/medical problems

Cost

Knowledge

I am too tired

Lack of interest

I don't live in a safe area

Other

Except from your commute to and from work/school, how do you get around most often?

Car/motorcycle

Walk

Bicycle

Public bus

Taxi

SECTION 2: NUTRITION

Please read: One serving of fruit is equal to 1/2 cup, which is equal to the size of a fist or cupped hand or a tennis ball. One serving of vegetables is also equal to 1/2 cup, except for salad greens and spinach which is equal to 1 cup.

10.

Not counting juice, how many 1/2 cup servings of fruits do you eat each day on average?

1-2

2-3

3-4

4-5

6 or more

11.

How many 1 cup servings of green salad do you eat each day on average?

1-2

2-3

3-4

4-5

6 or more

12.

Not including French fries, fried potatoes, or potato chips, how many 1/2 cup servings of potatoes do you eat each day on average?

1-2

2-3

3-4

4-5

6 or more

13.

How many 1/2 cup servings of carrots do you eat each day on average?

1-2

2-3

3-4

4-5

6 or more

14.

Not counting carrots, potatoes, fried vegetables or salad, how many 1/2 cup servings of vegetables do you eat each day on average?

1-2

2-3

3-4

4-5

6 or more

15.

What stops you from eating more servings of fruits and vegetables each day?

I eat 3 or 5 or more servings of fruits and vegetables each day

Fruits and vegetables cost too much

Fruits and vegetables are not easy to find

I don't like the taste

I don't know how to cook fruits and vegetables

My family won't eat fruits and vegetables

Cooking fruits and vegetables is not easy

Other

16.

Do you know where the farmers markets and farm stands are in your neighborhood?

Yes

17.

If you answered yes to #16, when farmers markets are open (April - November), how often do you go to them to buy fruits and vegetables?

Once a week

Two or more times a week

Once a month

Two or more times a month

Less than once a month

SECTION 3: DEMOGRAPHIC INFORMATION

18.

What is your gender?

Male

Female

19.

What is your age group?

19-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70 and above

20.

What is your average household income each year?

0- $25,000

$26,000-$50,000

$51,000-$75,000

$76,000-$100,000

$101,000-$150,000

$151,000 or more

21.

What is the zip code of where you live?

22.

Choose your ethnic group?

White

African American

Latino

Asian / Pacific Islander

Native American

Other

23.

What is your current employment status?

Full-time

Part-time

Unemployed

Homemaker

Retired

Disabled

Student

24.

What is the highest level of education you completed?

High School Diploma

GED

Vocational or Trade School

Some College

College Degree

Some Graduate School

Graduate of Professional Degree

Other

25.

What is your marital status?

Single

Married

Separated

Divorced

Widowed

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