Stephen F. Austin State University

Participant Profile

Employee Wellness Connection

Personal Information

What is your first name?


What is your last name?


E-mail Address


What is your department?


What is your status?
    Faculty
    Staff
    Administration

SFA Post Office Box Number


What is your work phone number?


What is your fax number?


Gender:
    Male
    Female

Fitness Information

Rate Your Fitness Level
    Superior
    Excellent
    Good
    Fair
    Poor
    Very Poor

Are you currently participating in a regular fitness activity?
    Yes
    No

If yes, please list activities:


Hours per week

Optional Information:

Age:


Height:


Weight:


List medications presently taking


Do you have:
    High blood pressure
    Heart disease
    Diabetes

List other health risks of which we should be aware.


Physician name


Physician Phone


In case of emergency, contact


Emergency Contact Phone