Please complete the following form before we get started. It's all about you, your health, your cancer journey and your goals. The first medical section is mandatory before we can start working on an exercise program together. The rest is designed to give both of us a detailed starting point, physically and emotionally. If there's something you don't know or don't feel comfortable answering, feel free to skip to the next question. Look forward to working with you.

About You

First name

Last name

Email

General Medical History

Have you ever been diagnosed with a heart condition?

Yes

No

Have you ever been diagnosed with high blood pressure?

Yes

No

If yes to either heart condition or high blood pressure, please provide details below, including medication.

Do you ever feel pain in your chest, either at rest or during activity?

Yes

No

Do you ever feel dizzy during exercise? Or have you lost consciousness in the last 12 months?

Yes

No

If yes to either pain or dizziness, please provide more detail below.

Have you ever been diagnosed with a chronic medical condition (other than cancer, heart disease or high blood pressure)?

Yes

No

If yes , please provide detail below.

Are you currently taking any medications for a chronic / long term medical condition? If yes, please provide detail below.

Do you currently have (or have had within the last 12 months) a bone, joint, or soft tissue (muscles, ligaments, tendons) injury that could be made worse by becoming more physically active?

Yes

No

If yes, please provide detail below.

Have you ever had a stroke? If yes, please provide detail.

Do you / did you smoke tobacco? If so, how much? If you've stopped, when did you give up? Do you vape?

Yes

No

If yes, please elaborate. Are you taking any medication - eg pain killers or steroids? Have you had a bone density (DEXA) scan? Have you had an MRI?

Do you have any metabolic conditions (including type 1 or type 2 diabetes or pre diabetes)? If yes, please provide details.

Do you have any mental health problems for which you are receiving treatment and/or medication? Please provide details if yes.

Do you have any respiratory diseases, including asthma? If yes, please provide details.

Do you have any other medical conditions not listed above (other than cancer)? Please provide details.

You Cancer Journey

What type of cancer were you diagnosed with? And when?

What stage is / was it?

Are you still in active treatment? (chemo, radio, immunotherapy)

Yes

No

Tell me about surgeries you have had, including dates and any ongoing side effects.

Have you had any lymph nodes removed or radiated as part of your treatment? If so where and how many?

Do you have cording or lymphoedema? If so, where and how does it affect you?

Have you had chemotherapy?

Yes

No

If yes, which drugs and treatment dates. What are / were your main chemo side effects?

Have you had radiotherapy? If yes, please confirm the dates and your main radiotherapy side effects?

Are you currently receiving any ongoing treatment (including hormone therapy)? If yes, please confirm what and how long for. When did you start?

Do you consider yourself in remission / NED?

Yes

No

I'm not sure

Do you have any ongoing side effects from any of your cancer treatment? How do they affect your day to day life?

Have you had any complementary therapies during or after cancer treatment? eg physiotherapy, nutritionist, acupuncture, counselling. Are you still in treatment?

As a cancer patient, what are you struggling with most at the moment? Both physically and mentally?

Has your weight / body composition changed as a result of cancer treatment? If so, how?

How do you feel about your body since cancer? Has your relationship with your body changed since before cancer?

Is there anything else you'd like to mention about your cancer journey?

Exercise and Movement

Tell me about your average week's exercise? How many times per week? How long? What activities do you do? How has this changed since cancer?

How does exercise make you feel?

What's your favourite type of exercise?

Do you walk and if so where, for how long and how often?

What holds you back from doing more exercise?

What exercise equipment do you have at home?

Do you have a smart watch that tracks your heart rate and activities?

Goals: What would you like to achieve?

Last question! Is there anything else that you think is relevant that hasn't been covered?

Signature, confirming you consent to take part in exercise.

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Health questionnaire & consent

About You

General Medical History

You Cancer Journey

Exercise and Movement

Goals: What would you like to achieve?