Team Wellness | Data Collection Form
Participant Demographics
Chapter/State Program *
Local Program *
Your answer
Participant Name (First Name, Last Initial) *
Your answer
Testing Time *
1 = Pre-test for the season; 2 = Post-test for the season
Attendance (out of 8 sessions)
Participants' engagement in program
1 = Present, but not engaged; 2 = Some engagement but not consistent; 3 = Engaged; 4 = Very Engaged & Enthusiastic
How many times in Team Wellness program? *
1 = first time; 2 = second time, etc.
Participant/Partner *
1 = Participant with Intellectual/Developmental Disability; 2 = Partner
Gender *
1 = Male; 2 = Female
Age (in years) *
Your answer
Physical Limitation *
1 = no limitations; 2 = minor difficulty; 3 = uses wheelchair, cane, walker, prosthesis, etc.
Height (in inches) *
Your answer
Weight (in pounds) *
Your answer
BMI
Your answer
Blood Pressure | Systolic *
Top Number
Your answer
Blood Pressure | Diastolic *
Bottom number
Your answer
Nutrition Information
Fruits & Veggies - Servings per day *
Your answer
Whole Grains - Servings per day *
Your answer
Water - Servings per day *
Your answer
Non-fat/Low-fat milk - Servings per day *
Your answer
Fast food - Servings per day *
e.g, fries, burgers, etc
Your answer
Soda Pop (Soft drinks) - Servings per day *
Your answer
Drinks when thirsty (List all choices) *
1 = water; 2 - fruit juice; 3 = soft drinks; 4 = sport drink; 5 = milk
Your answer
When drinking soda pop/soft drink, is it diet or regular? *
1 = diet, 2 = regular/non-diet
Physical Activity
# of Push-ups in 1 minute *
Your answer
Type of Push-up *
1 = Wall; 2 = modified; 3 = regular
Plank Hold *
# of seconds plank can be held
Your answer
Sit to Stand *
# of full sit to stands in 60 seconds
Your answer
Walking *
# of laps in six (6) minutes
Your answer
Distance of Lap (if known)
Please identify if measured in meters or yards
Your answer
# of Days in past week of exercising at least 30 minutes *
1 = no days; 2 = one to two days; 3 = three to five days; 4 = everyday
Hours per day in last week of TV, Computer & Video Games *
1 = zero to two hours; 2 = two to four hours; 3 = four to six hours; 4 = over six hours
Exercise outside of Special Olympics *
1 = no; 2 = yes
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