Rossell Fitness Cancer Rehab Health Questionnaire

  • Date Format: DD slash MM slash YYYY
    (Please note you may change your decision at any time). For the remainder of this questionnaire, you’ll be asked about several topics, including some from the list above. If you’re not comfortable talking about these, simply write “Opt out” in the space designated for your answer.
  • Enter weight to the nearest kilo
  • Please enter a number from 30 to 100.
    Here's how to do the test: Find your pulse at your wrist (the radial artery) or at your carotid artery in your neck. Using your index and middle finger, count the number of beats you feel in 10 seconds. ... Multiply the number of beats you count in 10 seconds by six to find the number of beats per minute.
  • Please list ALL of the diets that you can remember trying before, and if possible, the duration that you attempted these diets for. This will give me an idea of your metabolism and how reactive your body might be to what we are trying to do together!
    Select the option closest to your reality
  • If none, simply type NONE into the box
    For example: deep tissue massages, sauna time, manicure, pedicures (anything that you can do to take care of your body that adds up long term to better health). Other activities that do not cost anything include: watching comedy, cuddles, gentle walking, gentle stretching/yoga
  • Please state any health conditions that exist within your siblings, parents and grandparents eg cancers, diabetes, obesity, genetic diseases etc
  • If cancer, please include type/stage/site of cancer and type/site/stage of treatment
    Check all that apply
    Check all that apply
    Check all that apply
  • If you do not take any supplements simply type NONE
    Smoking may limit the effects of fitness that we are trying to achieve, it would be my recommendation that you look to reduce your consumption over the next weeks/months.
    Alcohol may limit the effects of fitness that we are trying to achieve, it would be my recommendation that you look to reduce your consumption over the next weeks/months.
    When a patient is referred by their doctor or oncologist, it is vital that the exclusion criteria are met prior to the exercise referral starting
  • This is not a required field in this form, however it will be a useful and interesting comparison if you are comfortable submitting this to me
    Please make sure that you have filled in ALL of the boxes with the correct information, if you have missed a box, the form will not submit.Once you click the submit button, there might NOT be a page that says 'submitted', don't worry if nothing pops up, your form will be emailed directly to me as long as you filled in all of the boxes and clicked on submit at least once! Thanks for fill in my form and I will be in touch very soon!You will get a personalised action plan based on the results of this questionnaire, please give up to 5-7 days for this to be developed for you