¡Vida! Educational Series

Talk # 5: Easing into Exercise for Healthy Happy Recovery

October 26, 2012 Location: ______

General Information Survey

1- I am a: (please circle all that apply) Other ______

Breast cancer survivor Relative of a breast cancer survivor

Caregiver of a breast cancer survivor CPG (Community Partner Group)

Lay health worker/ promoter Health care professional

2- My residence is in city/town: county: zip code:

3- My health insurance is: (please circle all that apply) AHCCCS PCAP

Private (please specify) (HMO/ PPO) ______

Other______No health insurance Medicare

______4- Age: Gender :

5- Race/ Ethnicity (please circle all that apply):

Native American Pacific Islander Caucasian Mixed race

Asian African American Other ______

6- How did you hear about this session?

7- As a result of viewing this presentation, will you? (circle all that apply):

Seek medical care Yes No

Share the information with others, if yes, who:______Yes No

Change your practice Yes No

Other:

Before viewing the session: My knowledge about this topic is: (circle only one answer)

none at all very little somewhat a lot

Please answer these questions before viewing this session:

1.  Name three benefits of exercising after cancer treatment.

2.  What type of exercise (if any) is safe for breast cancer survivors with lymphedema?

3.  In the next week, how many days do you plan to exercise vigorously enough to increase your heart rate for 10 minutes or more?

4.  In the next week, how many days do you plan to lift weights or do other resistance exercises?

After viewing the session: My knowledge about this topic is: (circle only one answer)

none at all very little somewhat a lot

Please answer these questions after viewing this session:

1.  Name three benefits of exercising after cancer treatment.

2.  What type of exercise (if any) is safe for breast cancer survivors with lymphedema?

3.  In the next week, how many days do you plan to exercise vigorously enough to increase your heart rate for 10 minutes or more?

4.  In the next week, how many days do you plan to lift weights or do other resistance exercises?

AFTER VIEWING THE SESSION

PLEASE COMPLETE THIS SURVEY

TODAY’S DATE: 10/26/12 / VIDA! Monthly Educational Series – Promoting Good Health
PROGRAM TITLE: Easing into Exercise for Healthy
Happy Recovery / SPEAKER: Joy Kiviat, PhD, MSN, RN (OCN), ACSM
STRONGLY DISAGREE / DISAGREE / NO
OPINION / AGREE / STRONGLY
AGREE
1-This topic is of interest to me / 1 / 2 / 3 / 4 / 5
2-This topic is relevant to my life and loved ones’ / 1 / 2 / 3 / 4 / 5
3-I learned new information / 1 / 2 / 3 / 4 / 5
4-The teaching techniques were conducive to learning / 1 / 2 / 3 / 4 / 5
5-The speaker was prepared / 1 / 2 / 3 / 4 / 5
6-The educational objectives were met / 1 / 2 / 3 / 4 / 5
7-I would not have been able to attend a lecture on this topic if it had not been available via the telemedicine / 1 / 2 / 3 / 4 / 5

What other topics would you like to see addressed?

Did you feel there was a bias toward any particular product or company? Yes____ No _____

If yes, please explain:

COMMENTS:

THANK YOU

You may submit the completed forms in any of the following ways:

Via fax: (520) 626-5583

Attn: Bettina Hofacre

Via mail: University of Arizona

Cancer Center

Attn: Bettina Hofacre

1515 N. Campbell Ave

Tucson, AZ 85724

Via e-mail to:

If you have any questions please contact:

Bettina Hofacre at (520) 626-3265

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