CLIENT EXERCISE HEALTH INFORMATION FORM

GENERAL INFORMATION

Please circle one of the following: Mr. Mrs. Miss Ms.

Last Name:______First Name:______

Address:______

City:______Province:______Postal Code:______

Date of Birth: Day:______Month:______Year:______Age:______

Home Phone:______Cell Phone:______

Email:______

Emergency Contact:______Emergency Phone#:______

MEDICAL INFORMATION

Oncologist:______Phone #:______

Diagnosis:______

Date of diagnosis: Month______Year______

Are you currently undergoing treatment? Please circle: YES NO

Please circle your current treatment: SURGERY CHEMOTHERAPY RADIATION

Do you have anymetastasis? YES NO Location:______

Do you have lymphedema? YES NO Location:______

If not in active treatment, how many years have you been post-treatment? ______years

Which hospital(s) are you being treated at?______

Please list the name of any medication(s) you are taking:______

______

Have any drugs you are taking caused side effects that might cause problems for exercising?

______

Is your doctor aware of any of the above problems associated with the drug side effects as they relate to exercise: YES NO

Do you have a cardiac pacemaker or any other implants? YES NO

Do you have any of the following conditions? YES NO

Circulatory Problems ______Heart Condition ______Respiratory Disease ______

Diabetes ______High Blood Pressure ______Visual Impairment ______

Epilepsy ______Inner Ear Disorder ______Pregnant ______

Hearing Impairment ______Fatigue ______Bone/joint problems______

Weight loss ______Weight gain ______

Do you have any allergies? Yes No What type of allergy? ______

Please describe any current injuries or pain you are experiencing:

______

Do you have regular treatments from any of the following health care professionals?

Physiotherapist______Chiropractor______Massage therapist______Acupuncturist______Dietician______Other______

EXERCISE INFORMATION

Do you currently exercise? YESNO

If yes, what do you do in the way of exercising? ______

Do you have any goals for yourself as a result of exercise? Please specify your goals as a result of exercise.______
______
What is your favorite form of exercise?______
______

CANSUPPORT INFORMATION

How did you hear about CanSupport?______

Language of preference: Please circle English French

CanSupport offers a variety of programs and services that might be of interest to you. Would you like to be contacted by email to learn more? Please circle: YES NO

I give my consent to take the exercise program offered by Cedars CanSupport. I agree that by participating in the exercise program, I do so at my own risk and release Cedars CanSupport and its employees from all liability.

Signature______Date:______

Cedars CanSupport Resource Centres:

RoyalVictoriaHospital (RVH)

687 Pine Avenue West, Room A2.44

Montreal, Quebec, CanadaH3A 1A1

Telephone: 514-843-1666

Montreal GeneralHospital (MGH)

1650 Cedar Avenue, Room A7.116

Montreal, Quebec, CanadaH3G 1A4

Telephone:514-934-1934/local 42314

Cedars CanSupport thanks you for your interest and support.

Cedars CanSupport provides psychological, educational, practical and financial support to cancer patients and their families. All services are free and bilingual.

All personal information will remain within our organization and will not be shared with any external entity.

To be completed by physician

(mandatory for applicant’s acceptance into this program)

Dr. ______Date:______

Phone number______

  1. Our no-charge exercise program is offered to adults with cancer who have been diagnosed, are undergoing treatment or are in survivorship.
  2. We offer our program twice a week for 10 weeks.
  3. Individualized help is provided, when necessary, within the group exercise class.
  4. The following is a list of criteria that must be met for an individual to attend our exercise class:
  • Diagnosed with cancer
  • Adults 18 years of age or over
  • Ability to participate in an exercise program
  • Motivation to participate in an exercise program

I give my consent for the above applicant to participate in the no charge Cedars CanSupport Cancer Exercise Program.

Physician Signature ______Date ______

Comments: ______

Thank you for completing this form.