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IWH Wellness & Sport Evaluation Program
Demographic Questionnaire
Name: __________________________________________________________________________ Date: _____/_____/20______
(Last) (First)
Phone: (_____) __________________________
Address: _______________________________
How would you prefer we contact you?
Date of Birth: _____ / _____ / ______
Ethnicity: (Check all that apply)
African American
American Indian
Asian/Pacific Islander
Phone
Email
Gender:
Male
Caucasian (non-Hispanic)
Hispanic
Scandinavian
What is the highest level of education you have attained? (Please mark only one)
Less than a high school diploma
Some college or technical training
High school graduate
Associate’s degree or equivalent
What is your present work situation? (Check all that apply)
Employed full-time
Self-employed
Employed part-time
Unemployed
Semi-retired
Homemaker
Fully-retired
Student
Are or were you a student at Texas Woman’s University?
Yes, I am a current student
Yes, but I am not currently enrolled in any courses
Are you a current employee of Texas Woman’s University?
Yes
No
(Middle)
Email: _______________________
City _________________________ ST ______ Zip ________
Mail
Female
Other:
Bachelor’s degree
Graduate degree
On disability
Other:
Yes, I am a TWU alumnus
No
Please provide the name of a close relative or friend that we may contact, if necessary.
Name: ____________________________________________________ Phone: (_____) __________________________
Please provide the name of your physician.
Name: ____________________________________________________ Phone: (_____) __________________________
Is physician clearance required?
Yes No
Proof of physician clearance provided:
Yes No
Approved by: _____________
Proof of TWU employee/student status provided:
Yes No
Approved by: _____________
