Survivor Fitness Application

Full Name

First NameLast Name
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Why are you interested in beginning the Survivor Fitness program?
How did you hear about Survivor Fitness?
If referred by a provider, please list their name below
Provider Name (if applicable)
MEDICAL INFORMATION
Are you CURRENTLY undergoing any active treatements (Chemotherapy or Radiation).
Do you have any upcoming surgeries? If so, when are approximate dates?
Birthday (XX/XX/XXXX)
Age
Diagnosis
Year of Diagnosis
Forms of Treatment
Please list all surgeries and surgery dates related to cancer diagnosis.
Are you on medication for high blood pressure?
Do you take any medication to regulate your blood sugar?
Do you have a heart condition or are you on medication for your heart?
Current Medications (Please include all medications, not just those related to your cancer diagnosis.)
Treatment Facility
Name of Oncologist (To begin the program, you must have medical clearance. We will send them a release form.)
Oncologist Fax Number

Area CodeFax Number
Name of Primary Care Physician (To begin the program, you must have medical clearance. We will send them a release form.)
Primary Care Fax Number
Include Area Code
Names of any other Doctors you have seen or currently see. **Include Fax Numbers.
General Fitness and Health Information
Describe your current fitness or activity level.
Describe your fitness or activity level prior to diagnosis.
What are you looking for in a fitness routine?
Do you have any history of injuries or surgeries your trainer should know of (both related and unrelated to your cancer diagnosis)?
Is there anything else your trainer should know?
In addition to one-on-one personal training, Survivor Fitness offers individual consultations with a Registered Dietitian. Select which Program(s) you are interested in
If you would like to meet with a Registered Dietitian, please briefly explain your nutrition goals.

You will meet with a trainer twice a week. What is your weekly availability for workouts? Please select all available options."

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

Please include any specific instructions on availability.
ADDITIONAL INFORMATION

The below questions have no bearing on your program application. These questions simply help us obtain data so we can better illustrate the financial impacts of a cancer diagnosis. Your personal information will NOT be shared or identified.
Total current medical debt?
Please list estimated annual amount for additional medical expenses related to your cancer diagnosis.
Did your cancer diagnosis force a change in your employment status? If yes, please explain.
Should be Empty:

MEDICAL INFORMATION

General Fitness and Health Information

ADDITIONAL INFORMATION