ENRICHing Survivorship Registration Form

Registration Form
Please consider the questions below carefully and provide as much detail as possible.

If you are in any doubt about your ability to participate in the program, we recommend that you consult your doctor. Feel free to call us on (02) 6257 9999 to check any of the questions.

A carer or family member is welcome to accompany the cancer survivor. A separate registration form must be completed for the carer or family member attending with you.

Confirmation of your place in the program will be made by phone or email.
Section 1: Personal Details
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Are you a:*

SurvivorCarerPartnerFamily member
Gender*

MaleFemaleI prefer not to sayI prefer to self identify:
Section 2: Cancer Treatment

(Skip to the next section if you are a Carer/Partner/Family Member)
Cancer Type(s):*
Date of diagnosis: *

DayMonthYear
Treatment Received:*

SurgeryRadiotherapyChemotherapyHormonal
Treatment Status:*

CompleteIncomplete; Provide details below:
Date completed treatment*

MonthDayYear
Date
Where did you receive your treatment?*
I am receiving long term treatment:*

NoYes; Provide details below:
Section 3: Person to be notified in case of emergency
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to you:*
Section 4: Ability to Participate
1. Are you able to safely participate in a progressive walking program? (A walking program that is tailored to your own ability and fitness level)*

Yes - no limitationsYes - with limitations (please specify)No, cannot participateLimitations:
2. Are you able to safely participate in a resistance training program? (Resistance training is designed to improve muscular strength. The program is tailored to individual needs)*

Yes - no limitationsYes - with limitations (please specifu)No, cannot participateLimitations:
3. Are you able to safely modify your diet, with emphasis on increasing fruit and vegetables?*

Yes - no limitationsYes - with limitations (please specifu)No, cannot participateLimitations:
Section 5: Pre-exercise Screening

The following questions are about your capacity to undertake physical activity at the ENRICHing Survivorship program:*

	Yes	No
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lost balance?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months>
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

8. Please provide details of all questions you responded 'Yes' to in Sections 5
Please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

If you answered 'YES' to any of the questions above in Section 5 or indicated any limitations in Section 4, a Medical Clearance will need to be completed by your GP / Specialist and returned with this registration.

The Medical Clearance form can be downloaded here:

Medical Clearance Form
9. Is there anything that makes exercise difficult for you?*
10. Do you take any medications? Please provide the names of your medications. *
Section 6: Program recruitment
How did you hear about the ENRICHing Survivorship Program?*
Should be Empty:

Section 1: Personal Details

Section 2: Cancer Treatment

Section 3: Person to be notified in case of emergency

Section 4: Ability to Participate

Section 5: Pre-exercise Screening

Section 6: Program recruitment