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Direction: Please respond to the following questions by placing a check mark

(√) in the answer box that corresponds to your response and/or fills in the blank
where indicated.

Student-Athlete Non-Student Athlete

Surname First name Middle name

Birthdate: Birthplace: Age: Height: Weight:

Religion: Email: Phone:
Complete Home Address:

Name of Parents*
Father: Mother:
Occupation: Occupation:
Contact no.: Contact no.:
(If living with a legal guardian) Name: Contact no.:
For Student-Athletes ONLY INTEREST related to Physical Ed.
**SPORTS Physical activities you usually do during free
Sports: time:
a) Singing; Genre: ___________________
**Position you play:
b) Dancing; Genre: ___________________
Current Team you are in: c) Swimming
Current Head Coach: d) Baking
e) Skateboarding
Number of years playing competitively: f) Running (Marathon)
**DANCE g) Trekking/Hiking
Name of dance troupe: h) Mountaineering
i) Camping
Dance Coach: j) Backpacking
Genre you are into: k) Picnic
Site 2 recent tournaments you have competed in: l) Bird-watching
Name of Tournament: m) Mountain Biking
n) Orienteering
Champion 1st runner-up 2nd runner-up o) Canyoneering
Rank: _______________________________________ p) Rock Climbing
q) Snorkeling
Special Award Received: r) Diving
s) Surfing
Name of Tournament: t) Canoeing
u) Kayaking
Champion 1st runner-up 2nd runner-up v) Sailing
Rank: _______________________________________ w) Fishing
Special Award Received: Others: __________________________

My Expectations for this subject: ____________________________________________________________

My Expectations for my P.E Teacher: ________________________________________________________
Expected grade (huwag mahihiya): __________________________________________________________

*About me (the funnier, the better): Legend:

* = required
** = if applicable
Student Worksheet 1
Physical Activity Pre-assessment Questionnaire
The following questions will help you analyze your physical activity preference and habits. It will help
you make decisions concerning your health and fitness level. This is NOT A TEST. Answer the questions as
honestly as possible. Encircle the letter of your answer.

1. In the past academic year, how active were you during your P.E class?
a. I did not join the P.E class.
b. I just stood/walked around during class.
c. I ran and played a bit.
d. I ran and played most of the time.

2. In the past week, how many days were you active for at least 60 minutes?
a. 0 b. 1 to 2 days c. 3 to 4 days d. 5 or more days

3. In the past week, how many days did you spend watching TV or playing video games for more than 2
a. 5 or more days b. 3 to 4 days c. 1 to 2 days d. 0

4. In the past week, I spent most of my leisure time ______.

a. reading books, watching TV, playing video games, surfing the net, and sleeping.
b. walking the dog, helping with household chores, cleaning my room, and running errands.
c. performing moderate intensity sports, games and dance.
d. performing high intensity sports, games and dance.

5. In the past week, how many hours (i.e., average) in a day did you spend playing video games or
surfing the net?
a. more than 4 hours b. 3 to 4 hours c. 1 to 2 hours d. less than an hour

6. In the past week, how many hours (i.e., total) of your weekend did you spend in moderate to high
a. more than 4 hours b. 3 to 4 hours c. 1 to 2 hours d. less than an hour

7. In the year, how many minutes (i.e., total) of your P.E class did you spend playing or dancing or
a. less than 15 mins b. 15 to 30 mins c. 31 to 45 mins d. more than 45 mins

8. In the past week, how would you classify your participation in various physical activities?
a. inactive b. lightly active c. moderately active d. very active

Score: ______________
HEROSAN A. DELA PEÑA, LPT Rating: ______________
Physical Education Teacher

This is to advise that a Student Deficiency Notice will be issued for every non-compliance of requirements for
Physical Education and Health (1, 2, 3, or 4). A verbal notice of non-compliance will also be issued prior to
this. Failure to comply may result to a failing grade but resolution may be accomplished by complying to the
prerequisite given by the teacher and be submitted on a given date.

Signature Over Printed Name