Less than 30 minutes 30 minutes to 1 hour Over 1 hour ☐ ☐ ☐ 29. About how many hours of TV does your child watch every day? Less than1 hour 1-3 hours More than 3 hours ☐ ☐ ☐ 30. About how many hours is your child on a computer every day? Less than 1 hour 1-3 hours More than 3 hours ☐ ☐ ☐ Does not have a computer ☐ 31. About how many hours does your child spend outside every day? Less than1 hour 1-3 hours More than 3 hours ☐ ☐ ☐ 32. About how many hours are spent reading with your child every day? Less than 15 minutes 15-30 minutes 30 minutes to1 hour More than 1 hour ☐ ☐ ☐ ☐ 33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc.? Yes No Does not do activities like that ☐ ☐ ☐ 34. Does your child get buckled in a car seat or wear a seat belt when riding in a car? No ☐Yes ☐ 35. Do you have guns in the home? No ☐Yes ☐ If yes, are they locked up? No ☐Yes ☐ 36. What activities is your child involved in: Riding bike Dance/movement Skate boarding ☐ ☐T-ball/baseball ☐ ☐ Karate Video games Girl Scouts/Boy Scouts ☐ ☐ ☐ Soccer Playing a musical instrument ☐ ☐ Reading Playing with friends ☐ ☐ Other team sports Other activity(s) ☐ Too young to be involved in activities ☐
☐ Less than 30 minutes ☐ 30 minutes to 1 hour ☐ Over 1 hour 29. About how many hours of TV does your child watch every day? ☐ Less than1 hour ☐ 1-3 hours ☐ More than 3 hours 30. About how many hours is your child on a computer every day? ☐ Less than 1 hour ☐ 1-3 hours ☐ More than 3 hours ☐ Does not have a computer 31. About how many hours does your child spend outside every day? ☐ Less than1 hour ☐ 1-3 hours ☐ More than 3 hours 32. About how many hours are spent reading with your child every day? ☐ Less than 15 minutes ☐ 15-30 minutes ☐ 30 minutes to1 hour ☐ More than 1 hour 33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc.? ☐ Yes ☐ No ☐ Does not do activities like that 34. Does your child get buckled in a car seat or wear a seat belt when riding in a car? ☐Yes ☐ No 35. Do you have guns in the home? ☐Yes ☐ No If yes, are they locked up? ☐Yes ☐ No 36. What activities is your child involved in: ☐ Riding bike ☐T-ball/baseball ☐ Dance/movement ☐ Skate boarding ☐ Karate ☐ Video games ☐ Girl Scouts/Boy Scouts ☐ Soccer ☐ Playing a musical instrument ☐ Reading ☐ Playing with friends Other team sports ☐ Other activity(s) ☐ Too young to be involved in activities
healthlittoolkit2-tool11b.docx