Participant Health History Form HomeParticipant Health History Form HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.I would like to apply to attend the following living well activity:(Required) Living Well Gentle Yoga (Cottesloe) Living Well Pilates (Murdoch) Living Well Exercise (Online) Metastatic Wellness Day (Cottesloe) 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) I agree to attend the first session and most subsequent sessions.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.About YouYour Name(Required) First Last Email(Required) Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Age Gender Your Address Street Address Address Line 2 City ZIP Code Emergency Contact DetailsEmergency Contact Name(Required)Emergency Contact Number(Required)Emergency Contact Relationship(Required) For the following questions, providing as much detail as you can will enable us to implement a safe and effective exercise program.Breast Cancer History1. When where you diagnosed with breast cancer?(Required) 2. What stage of breast cancer were you diagnosed with?(Required) 3. Have you been diagnosed with any metastases?(Required) If yes, please list the sites: If you have bone metastases, please tick the locations below and provide a recent Imaging report which identifies these sites. Pelvis (i.e., hip) Ribs/Thoracic spine (i.e., chest/ upper back) Lumbar spine (i.e., lower back) Femur (i.e., thighs) Humerus (i.e., upper arm) 4. Have you had the following treatment? Please tick and provide details.Surgery Completed Current If not current list details Radiation Therapy Current If not current list details Hormone Therapy Current If not current list details Chemotherapy Current If not current list details Other Current If not current list details 5. Please tick Yes or No. If Yes, please provide further details.Do you participate in physical activity/exercise?(Required) Yes No If yes provide details Do you experience fatigue or shortness of breath at rest, during usual activities (e.g., climb stairs, carrying groceries, brisk walking) or exercise?(Required) Yes No If yes provide details Do you experience sudden tingling, numbness, or loss of feeling?(Required) Yes No If yes provide details Do you experience any swelling, pains, or cramps in your leg?(Required) Yes No If yes provide details Have you been told that you have high blood pressure or high cholesterol?(Required) Yes No If yes provide details Have you been told that you have cardiovascular or pulmonary conditions?(Required) Yes No If yes provide details Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose your balance?(Required) Yes No If yes provide details If you have diabetes, have you had trouble controlling your blood glucose in the last 3 months?(Required) Yes No If yes provide details Have you ever been told that you have osteoporosis?(Required) Yes No If yes provide details 6. Do you currently have or previously had any of the following: PICC line/chest port Cording Lymphoedema 7. Did you experience any other treatment-related side effects (e.g., fatigue, nausea, neuropathy)? Please provide details below: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) Yes No If yes, please provide details:9. Have you ever had any surgery (unrelated to cancer)?(Required) Yes No If yes, please provide details:10. Please list all your current prescribed medications. Fill each column for each medication.Medications, Duration (in years/months), Reason (which medical condition) and other comments11. Are you able to get down on, and up off the floor comfortably?(Required) Yes No 12. If you feel there are any other medical conditions, previous surgeries or injuries that may impact your ability to perform exercise, please provide details below:
20 years strong