LIVESTRONG at the YMCA Intake Form

YMCA Branch Preference

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Contact Method

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Sex

How did you hear about this program?

What is your highest level of education

What is your race? (check all that apply)

Are you of Hispanic, Latino(a), or Spanish Origin?

Are you a member of the YMCA?

Employer Name

Where were you treated?

Physician Name

Have you ever had any of the following health conditions (Select all that apply) ?

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

Cancer Diagnosis Date (MM/DD/YYYY)

Date

Surgery?

If Yes, date of most recent surgery:

Chemotherapy?

If Yes, date of last treatment:

Radiation?

If Yes, date of last treatment:

Do you have an implemented port or Central Venous Access Catheter?

If yes, specify location:

Are you experiencing peripheral neuropathy (i.e. tingling/loss of sensation in your fingers and/or toes)?

If yes, specify location:

Has the cancer spread to any bones?

If yes, specify location:

Have you had any lymph nodes removed?

Where have you had lymph node involvement?

Check all that are true:

Are there any other medical illnesses, injury, or issues (physical or psychological) we should be aware of?

If yes, please explain:

Configurable list

Describe your health at the present time:

Do you participate in exercise regularly?

Please list the TYPES of exercise you participate in regularly

Please describe the FREQUENCY of your exercise:

Please describe the INTENSITY of your exercise:

Do you have any physical limitations that restrict your daily living activities or ability to exercise?

Are there any limitations since your cancer diagnosis?

If yes, please explain

If you're working, what is your level of activity at work:

If you're not working, when did you stop?

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?

THANK YOU FOR COMPLETING

THE LIVESTRONG AT THE YMCA

INTAKE FORM!

Please hit the "submit" button below and

allow 48-72 business hours for the YMCA Leader to get back to you!

LIVESTRONG at the YMCA

HEALTH INFORMATION

YMCA STAFF only