Physical Wellness Assessment

Exercise Consult

Thank you for sharing a bit about your cancer history. We look forward to supporting you in staying active and building strength at your pace.
First Name
Last Name
Email Address
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Street Address
City
State
Zip Code
Name of Referring Clinician
Cancer History (share whatever you feel comfortable with).
How would you rate your physical strength for everyday tasks (e.g., carrying groceries, climbing stairs, standing up from a chair)?

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1 is Very low/poor (1), 5 is Very good (5)
How would you rate your typical energy level throughout the day (e.g., feeling alert, able to get through daily routines without feeling worn out)?

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1 is Very low/poor (1), 5 is Very good (5)
How confident do you feel in your ability to start and stick with an exercise routine (e.g., showing up for workouts, following a plan, staying consistent even on busy days)?

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1 is Very low/poor (1), 5 is Very good (5)
How would you rate your overall physical and emotional well-being (e.g., feeling physically and emotionally supported)?

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1 is Very low/poor (1), 5 is Very good (5)
What types of movement do you enjoy or feel most comfortable with?
Feel free to share anything else about your movement—what’s been feeling good, what’s been challenging, or what you’re hoping to work toward.
Have you been medically cleared for exercise?
How did you hear about 2Unstoppable?

Other
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Exercise Consult