Livestrong at the YMCA Enrollment Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone Call
Text
How did you hear about the program?
Current/Former Program Participant
Doctor/Other Health Care Professional
Employer
Family/Friend/Word of Mouth
Health Insurance Company
Media/Marketing
Screening Event/Health Fair
Y Staff Member/Volunteer
Other
What is your highest level of education?
Less than High School
High School Diploma or GED
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Professional Degree
Other
Are you of Hispanic, Latino or Spanish Origin?
Yes
No
Prefer not to answer.
What is your race? (Check all that apply)
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
A race not listed here
Prefer not to answer
Are you a member of the Y?
Yes
No
Employer Name (If referred you)
Health Information
All information provided will be held confidential under HIPAA Laws. Please fill out the form to your best of ability so that your Instructor for the LIVESTRONG class can prescribe a safe and effective workout according to your Medical History and current symptoms.
Where were you treated
Physician Name
First Name
Last Name
Have you ever had any of the following health conditions (Select all that apply)
Pulmonary (lung) Problem
Heart Problems or Surgery
Diabetes
Altered Heart Rate
Dizziness or Fainting (unrelated to cancer treatment)
Chest, Neck or Arm Pain
Pain or Cramping in Legs While Walking
Short-Term Weakness on One Side of the Body
Elevated Blood Pressure
High Cholesterol
Smoker or Previous Smoker
Arthritis
Other
If you checked the box for a condition above, please describe briefly the condition and it's effect on your life at this present time:
Type of Cancer:
Bladder
Bone
Brain
Breast
Cervical
Colon and Rectal
Endometrial
Esophageal
Head and Neck
Kidney (renal cell)
Leukemia
Liver
Lung
Lymphoma
Myeloma
Oral
Ovarian
Pancreatic
Prostate
Rectal
Melanoma
Skin (Non Melanoma)
Stomach (gastric)
Testicular
Thyroid
Uterine
Other
Cancer Diagnosis Date (MM/YYYY)
Surgery?
No
Yes
If yes, date of most recent surgery:
Chemotherapy?
No
Yes
If yes, date of last treatment:
Radiation
No
Yes
If yes, date of last treatment:
Do you have an implemented port or Central Venous Access Catheter?
No
Yes
If yes, please specify location:
Are you experiencing peripheral neuropathy (i.e. tingling/loss of sensation in your fingers and/or toes)?
No
Yes
If yes, please specify location:
Has the cancer spread to any bones?
No
Yes
If yes, please describe where:
Have you had any lymph nodes removed?
No
Yes
If yes, where have you had lymph node involvement?
Head and Neck
Left Lower Extremity
Right Lower Extremity
Left Upper Extremity
Right Upper Extremity
Check all that are true:
I have been DIAGNOSED with Lymphedema.
I am currently experiencing STIFFNESS or LOSS OF RANGE OF MOTION in the area that the lymph nodes have been removed.
I am currently experiencing PAIN or DISCOMFORT in the area that the lymph nodes have been removed.
Are there any other medical illnesses, injury, or issues (physical or psychological) we should be aware of? (if yes please specify)
List current medications, including vitamins and over the counter (If not applicable, record 0)
Describe your health at the present time:
Poor
Fair
Good
Very Good
Excellent
Do you participate in exercise regularly?
Yes
No
Please describe the FREQUENCY of your exercise:
Daily
2-6 times per week
Once a week
Less than once a week
Monthly
Please describe the INTENSITY of your exercise
Light
Moderate
Heavy
Please list the TYPES of exercise you participate in regularly
Do you have any physical limitations that restrict your daily living activities or ability to exercise? (If yes, please explain)
Are there any limitations since your cancer diagnosis? (If yes please explain)
If you're working, what is your level of activity at work:
Sedentary
Light
Moderate
Vigorous
Not Relevant
If you're not working, when did you stop?
-
Month
-
Day
Year
Date
Describe your past experience with resistance training and aerobic training
What expectations do you have from this program?
Do you have any concerns about starting this exercise program?
Submit
Should be Empty: