Three-Day Cancer Retreat Application

THREE-DAY CANCER RETREAT APPLICATION

Section I: Personal information

1. Name ______Date ______

2. Address ______

City ______State ______Zip______

3. Home phone ______Cell phone ______

Email ______

4. Occupation or brief work history ______

______

5. I am working : Full-time _____ Part-time _____ Not working _____ Retired _____

6. Age ______Birthdate ______

7. Name of spouse/companion (s/c) ______Age of s/c ______

Would s/c accompany you on retreat? ______

8. Occupation of s/c ______

9. Age(s) of children, if any ______

Section II: Your medical/health status

10. Are you presently under the care of an oncologist? Yes ______No ______

Date of last contact ______

11. Name of oncologist or primary medical doctor ______

City/state ______Phone ______

12. Your cancer diagnosis (please be specific) ______

13. Do you have any metastases (please be specific)? ______

______

14. Approximate date of initial diagnosis ______

15. Dates of recurrence, if any ______

16. Please list the medical treatments you are currently receiving:

Type of treatmentApprox. start dateProjected end date

(if known)

______

______

______

17. Please list all significant surgical and medical procedures prior to current therapy (cancer and non-cancer related)

Procedure (e.g., surgery)Approx. datesTherapyApprox. dates

______

______

______

18. If known, what medical therapies are projected for your future?

______

______

19. If you have any in-dwelling tubes, pumps or other devices, please list them here:

______

______

20. Please describe any medical or personal care needs that will need attention during the weekend?

______

21. Are you currently taking medication for pain, depression or other conditions?

Medication:Prescribed for:Dosage:Approx. starting dates:

______Pain ______

______Anxiety/Depression______

______Sleep ______

______Other ______

22. Are you currently a smoker? ______

23. Your height ______weight ______

24. How are you feeling physically? ______

______

25. Are you in pain at present? ______

If yes, please describe: ______

______

Section III: Use of complementary approaches

26. Please list below the complementary / adjunctive therapies that have supported you throughout or prior to your cancer journey (e.g., massage, yoga, acupuncture,healing modalities such as Reiki, support groups), starting with the most current.

Currently utilizing:

Type Approx. start date

______

______

______

______

Have utilized in the past:

Type Approx. start dateApprox. end date

______

______

______

Section IV: Psycho-social concerns

27. Please list briefly any major stresses, life changes or losses that preceded the onset of the cancer or of recurrence.

______

______

28. Please list the current areas of greatest stress in your life presently (e.g., cancer therapy, relationships, work, finances, etc.)

______

______

29. Are you currently seeing a psychiatrist, psychologist or other counselor? ______

If yes, start date: ______

Diagnosis (if applicable): ______

If any medications were prescribed, please include in Q. 21.

30. What has been the hardest part of your cancer journey? ______

______

______

31. What are the major sources of support or nurture in your life? ______

______

______

32. How is your morale? ______

______

Section V: Retreat-specific questions

33: What are your reasons for wanting to attend the retreat? ______

______

______

34: Do you have any concerns or fears about participating in the retreat? If so, please explain. ______

______

______

35: How did you learn about the retreat? ______

______

______

36. Can you eat Smith Center’s balanced mostly vegetarian meals which are high fiber & low fat? Note that dairy and eggs are available on the side as an option. No meat, poultry or fish is served at the retreat. Yes ______No ______

Do you have any special nutritional needs that our staff should know about?

______

______

37. Do you have allergies to foods or medications? Yes ______No ______

If yes, please specify and describe your reactions: ______

______

______

38. Do you have any physical limitations that would make it difficult for you to participate in the program as described in our informational materials (including climbing one flight of stairs)? If so, please describe.

______

______

Thank you for your application. If anything is unclear or if you need

additional information, please contact Erin Price Schabert at 202-483-8600 or

Please return your application to:

Smith Center for Healing and the Arts

1632 U Street, N.W.

Washington, D.C. 20009

By fax: 202-483-8601

By email:

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