1. Basic Details

1. Wellness And Health

a. In general, How is your health?

Excellent    Very Good    Good    Fair    Poor   

b. How do you describe your weight?

Very Underweight    Slightly Underweight    About The Right Weight    Slightly Overweight    Very Overweight   

c. Which of the following are you trying to do about your weight?

I am not trying to do anything about my health    Lose Weight    Gain Weight    Stay the same   

d. How much sleep do you usually get each night during the school week?

Less than six hours a night    6-7 hours a night    8-9 hours a night    More than 10 hours a night   

2. Physical Activity

a. During the last week, on how many days were you physically active for a total of at least 30 minutes per day?

O day    1 day    2 days    3 days    4 days    5 days    6 days    7 days   

b. Are you involved in any sports/games/dance in school?

Yes    No   

c. How important is it to you to feel like you are physically fit?

Very important    Important    Somewhat Important    Not too important   

d. Outside of the school, how much of the time do you spend during a typical day sitting and watching television,
playing on the computer, or doing other sitting activites?

Less than 1 hour per day   1 to 2 hours per day   3 to 4 hours per day    5 to 6 hours per day    7 to 8 hours per day   More than 8 hours per day   

3. Nutrition

a. Dietary preference

Vegetarian   Non-Vegetarian  

b. During the past month, how often did you go hungry because there was not enough food in home?

Never    Rarely   Sometimes    Most of the time    Always  

c. During the past week, how many times per day did you eat fruit, such as apple, mango, banana, pineapple, papaya, jackfruit, guava, or chikoo?

Did not eat fruit in the past week    Less than one time per day    1 time per day    2 time per day    3 times per day   4 times per day    5 or more times per day   

d. During the past week, how many times per day did you eat vegetables, such as cauliflower, ladyfinger,
pumpkin, brinjal, cabbage, spinach, peas, tomato, cucumber, or beans?

Did not eat vegetables during the past week    Less than one time per day    1 time per day    2 time per day   
3 times per day   4 times per day    5 or more times per day   

e. How often are the vegetables you eat cooked or fried in oil?

Never    Rarely    Sometimes    Most of the time    Always  

f. During the past week, how many times per day did you eat meat or fish, such as chicken, beef, mutton, or shrimp?

I did not eat meat or fish during the past week    Less than one time per day    1 time per day    2 time per day   
3 times per day   4 times per day    5 or more times per day   

g. During the past week, how many times per day did you drink carbonated soft drinks,
such as Thumbs up, Sprite, Seven up, Coke, Pepsi, Limca or Fanta?

I did not drink carbonated soft drinks during the past week    Less than one time per day    1 time per day    2 time per day    3 times per day   4 times per day    5 or more times per day   

h. During the past week, on how many days didi you eat at a fast food restaurant or at places serving quick meals (e.g. McDonalds,
KFC, Nirula's, Monginis, Pizza Hut, samosas, patties, pastries, rolls/frankies, panipuri/phuckha, chaat, burgers, noodles, tikkis, or ice creams)?

0 day    1 day    2 days    3 days    4 days   5 days    6 days    7 days   

i. In your School, have you been taught about the benefits of healthy eating, including eating more fruits and vegetables?

Yes    No    Unsure   

j. In your Home, have you been taught about the benefits of healthy eating, including eating more fruits and vegetables?

Yes    No    Unsure   

k. Is there a source of clean drinking water at school?

Yes    No    Unsure   

l. Is there a source of clean drinking water at home?

Yes    No    Unsure   

m. What is the source of drinking water at home?

Piped    Municipality    Drawn from well    Drawn from river, lake, or pond    Purchased from a vendor    Filtered    Unsure   

4: Hygiene

a. During the past month, how many times per day did you usually clean or brush your teeth?

I did not clean or brush my teeth during the past month    Less than 1 time per day    1 time per day    2 times per day   
3 times per day    4 times per day    5 or more times per day   

b. During the past month, how often did you wash your hands before eating?

Never    Rarely    Sometimes    Most of the times    Always   

c. During the past month, how often did you wash your hands after using the tollet or latrine?

Never    Rarely    Sometimes    Most of the times    Always   

d. During the past month, how often did you use soap when washing your hands?

Never    Rarely    Sometimes    Most of the times    Always   

Are the toilets or latrines clean at school?

Yes    No    There are no toilets or latrines at school   

5. Medical Care and Medical History

a. When you are sick, are you able to get to a clinic or hospital if you need to see a Doctor?

Never    Rarely    Sometimes    Most of the times    Always   

b. If you were NOT able to go to a clinic or hospital when you needed to see a doctor, what was the reason?

I always go to the doctor when I am sick    Cost    Family objections    There was no one to take me  
The clinic or hospital was too far away    My family treated me at home    I went to a traditional healer   
I did not like the health care providers at the clinic or hospital   

c. During the past year, did a toothache cause you to miss class or school?

Yes    No   

d. Have you ever been told by a Doctor that you have the following? You may choose more than one option.

Asthma    Diabetes    Anemia    Tuberculosis    Malaria    Cancer    Obesity    Malnutrition    Thalassemia    I have never been told that I had any of these conditions   

e. Have you ever received a vaccination of any type?

Yes    No   

6. HIV/AIDS

a. Have you ever heard of HIV infection or the disease called AIDS?

Yes    No   

b. In your school, have you ever been taught about HIV infection or AIDS?

Yes    No   

c. In your school, have you ever been taught how to avoid HIV infection or AIDS??

Yes    No   

d. Have you ever talked about HIV infection or AIDS with your parents or guardians??

Yes    No   

e. Can a person who looks healthy have an HIV infection?

Yes    No   

7. Cigarette, Tobacco use, Alcohol, and Drugs

a. Have you ever smoked cigarettes or chewed guthka or pan masala?

Never    Tried it a few times    Smoke occasionally    Smoke regularly   

b. During the past month, on how many days did you smoke cigarettes?

I do not smoke cigarettes    1 to 2 days    3 to 9 days    10 or more days    Everyday   

c. Have any of your close friends ever tried smoking cigarettes or chewed gutkha or pan masala?

Yes    No    Unsure   

d. Which of your parents or guardians smoke?

Neither    Father or male guardian    Mother or female guardian    Both   

e. Do you think smoking is harmful to your health?

Yes    No    Unsure   

f. During the past month, have you seen any anti-smoking media messages (such as television, radio, billboards, posters, newspapers, magazines or movies)?

Yes    No    Unsure   

g. Have you ever tries alcohol(except for religious purposes)?

Yes    No   

h. In the past 6 months, how many times have you tried alcohol?

I have not tried alcohol    Once    A few times    Once a month    More than once a month    Once a week    More than once a week   

i. If you have tried alcohol, where were you the first time you had a drink alcohol?

I have never tried alcohol    At home    At a wedding ceremony    In a Puja/festival    At School    At someone else's home    Out on the street or in a park    Some other place   

j. If you DO drink alcohol, do you typically drink until you are intoxicated (drink)?

I do not drink alcohol    Yes    No   

k. Have any of your close friends ever tried beer, wine or other liquor (except for religious purposes)?

Yes    No    Unsure   

8. Illegal Drugs

a. Have you ever take any illegal drugs (examples include ghanja, weed, pot, hash, charas, inhaling fluids, crack, cocaine etc.)?

Yes    No    Unsure   

b. Have any of your close friends ever used illegal drugs (examples include ghanja, weed, pot, hash, charas, inhaling fluids, crack, cocaine etc.)?

Yes    No    Unsure   

c. During the past year, how many times have used illegal drugs (examples include ghanja, weed, pot, hash, charas, inhaling fluids, crack, cocaine etc.)?

1 or 2 times    3 to 9 times    10 or more times    Never   

d. Have you even take any drug in injection form?

Yes    No    Unsure   

9: Violence, Domestic Violence, Abuse, and Unintentional Injury

a. During the past year, how many times were you seriously injured?

0    1 to 2    5 to 6    7 or more   

b. During the past year, what was the major cause of the most serious injury that happened to you?

I was not seriously injured during the past 12 months   
I was in a motor vehicle accident or hit by a motor vehicle   
I fell   
I inhaled/swallowed something bad for me   
I was attacked or abuse or I was fighting with someone   
Something else caused my injury   
I was in a fire or burnt by something hot   

c. Do you wear a helmet when you ride on a motorbike or scooter?

Never    Rarely    Sometimes    Most of the time    Always   

d. Do you wear a seatbelt when you ride in a car?

Never    Rarely    Sometimes    Most Of the times    Always   

e. During the past year, were you injured in a motor vehicle accident, either as a passenger in the vehicle or as a pedestrian on the street?

Yes    No   

f. Have you ever NOT GONE to school because you felt you would be unsafe either at school or on your way to school.

Yes    No   

g. During the past year, how frequently have you experienced someone saying something intentionally rude or insulting to you?

Never    Rarely    Sometimes    Most of the times    Always   

h.Have you ever seen a violent act take place at home, school, or in your neighborhood?

Yes    No   

i. Do you feel safe when at home?

Never    Rarely    Sometimes    Most of the times    Always   

j. Do you feel safe when at school?

Never    Rarely    Sometimes    Most of the times    Always   

k. Do you feel when hanging out with friends?

Never    Rarely    Sometimes    Most of the times    Always   

l. Do you ever molested by anyone?

Never    Rarely    Sometimes    Most of the times    Always