Participant Health History Form

HomeParticipant Health History Form

All physical activity has some risk of injury. If you have multiple bone metastases, cardiovascular illness, or are unsure if movement is suitable for you, please check with your medical professionals. To help us offer you the most suitable activities, we ask you to provide up to date health information prior to participation in Living Well activities. Please fill and submit form below.

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I would like to apply to attend the following living well activity:(Required)
The Living Well program is generously funded by the community. Places are limited in group activities, please only register if you can commit to most sessions. Attendance at the first session is important.(Required)

About You

Your Name(Required)
DD slash MM slash YYYY
Your Address(Required)

Emergency Contact Details

For the following questions, providing as much detail as you can will enable us to implement a safe and effective exercise program.

Breast Cancer History

If you have bone metastases, please tick the locations below and provide a recent Imaging report which identifies these sites.

4. Have you had the following treatment? Please tick and provide details.
Surgery Completed
Radiation Therapy
Hormone Therapy
Chemotherapy
Other

5. Please tick Yes or No. If Yes, please provide further details.
Do you participate in physical activity/exercise?(Required)
Do you experience fatigue or shortness of breath at rest, during usual activities (e.g., climb stairs, carrying groceries, brisk walking) or exercise?(Required)
Do you experience sudden tingling, numbness, or loss of feeling?(Required)
Do you experience any swelling, pains, or cramps in your leg?(Required)
Have you been told that you have high blood pressure or high cholesterol?(Required)
Have you been told that you have cardiovascular or pulmonary conditions?(Required)
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose your balance?(Required)
If you have diabetes, have you had trouble controlling your blood glucose in the last 3 months?
Have you ever been told that you have osteoporosis?(Required)

6. Do you currently have or previously had any of the following:

8. Do you have any muscle, bone, or joint problems that you have been told could be made worse by participating in physical activity/exercise?(Required)

9. Have you ever had any surgery (unrelated to cancer)?(Required)

Medications, Duration (in years/months), Reason (which medical condition) and other comments

11. Are you able to get down on, and up off the floor comfortably?(Required)

13. In the event of a health emergency, the individual being treated is responsible for any ambulance costs. Do you have current ambulance cover?
*required fields

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