Cancer Questionnaire

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests and is safe and effective.

Title
First name
Last name
Date of Birth	/ /
Age
Email
Address line 1
Address line 2
City
Zip Code
Home Phone
Date Diagnosed	//
Type of Cancer

Specific Location (left/right breast, lung etc.)

Surgery Yes No
Type of surgery (if reconstruction for breast, see below) Date(s) of surgery
// // // //
Current side-effects of surgery (range of motion limitations, fatigue etc.)

Post-surgery Treatment (chemotherapy, radiation)

Length of Treatment/Final Date

If breast cancer, did you have axillary node dissection? Yes No
Number of nodes removed:
Currently undergoing chemotherapy? Yes No
Date of most recent treatment / /
Currently undergoing radiation? Yes No
Date of most recent treatment / /
Did you have reconstruction? Yes No
Type Date
/ / / / / / / /
Side effects of reconstructive surgery?

Current Medications due to cancer?

Medications for cancer or cancer complications?

Other medications (prescribed OTC, vitamins, herbs etc.)

Primary Care Physician at time of diagnosis:
Surgeon:
Oncologist:
Have you experienced any unusual side effects in any of the treatments you have undergone?	Yes No
Please Describe

What are your goals in an exercise program? Please name 3.

What is your history of exercise?

Are you currently working with a therapist (lymphdema or physical)? Yes No
If yes, please list name and contact information if available.

Any specific recommendations or contradications from your therapist?

Life In Focus
PO Box 12854
Overland Park, KS
66282