Cancer Rehab Health Questionnaire

Name*

Email*

Age*

Date of birth*

Phone*

Throughout our coaching partnership, there may be things that come up that you are or are not comfortable talking about. Topics such as your menstrual cycle (or lack thereof), pelvic floor health, nutrition, sleep, and stress may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me as your coach by checking the box. If you are not comfortable talking about these with me, leave the box blank.*

(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.

Height*

Weight (kg)*

Enter weight to the nearest kilo

Are you looking to do any of the following...*

Lose weight
Maintain your weight
Gain weight
Something else

If you are looking to lose weight, how much weight do you want to lose? (kg)

If you are looking to gain weight, how much weight do you want to gain? (kg)

How do you spend your time / what is your main occupation?*

Resting Heart Rate*

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.

Have you ever tried to diet before (this means to restrict calories/food in order to lose weight)?*

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!

Tell me about 3 things that you love to do, that make you feel happy... (hobbies/passtimes)*

Daily activity level*

Sedentary
Little incidental movement
Walk every day
On feet all day
Active job but no active hobbies
Train every day + sedentary job
Train every day + active job

Select the option closest to your reality

Have you ever found exercise enjoyable?*

Yes
No

What was the exercise that you enjoyed?*

If none, simply type NONE into the box

Is it in your budget to schedule in some TLC activities?*

Yes
No

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

Family medical history*

Please state any health conditions that exist within your siblings, parents and grandparents eg cancers, diabetes, obesity, genetic diseases etc

Have you suffered with any serious illness OR infections, at any time in your life? (if no, just write NONE) AND have you ever been hospitalised for extended periods?

If cancer, please include type/stage/site of cancer and type/site/stage of treatment

Have you ever lived in another country? If so, where?*

Were you born naturally?*

Natural birth
Cesarean

Were you breast fed?*

Breast fed
Bottle fed

Were you vaccinated as a child?*

Vaccinated
Not vaccinated

State any vaccinations or type NONE*

Did you receive antibiotics as a child?*

Yes
No

Do you take antibiotics regularly as an adult?*

Yes reguarly
No never
Yes occasionally

Do you have any of these skin symptoms?*

Check all that apply

Do you have any of these gut symptoms?*

Check all that apply

Do you have any of these bodily symptoms on a regular basis?*

Muscle cramps
Muscle twitches
Joint pains
Reoccurring injuries
Multiple one off injuries
None of the above

Check all that apply

Please go into detail if you suffer with joint pain or joint injuries. Type N/A otherwise*

Please check the box that best describes your sleep habits*

Sleep well and deeply through the night
Struggle to get to sleep but sleep through once asleep
Struggle to get to sleep and wake up in the night
Get to sleep fine, but wake up randomly in the night
Get to sleep fine and wake up at the same time in the night
Insomniac
Mixture of all of these conditions
None of these conditions

Please state your general bed time*

How many hours of sleep would you say you have generally*

Please describe your typical evening routine*

Select a choice that most describes you in the morning*

Jump out of bed feeling ready for the day
Struggle to get up but feel ok when I do
Need COFFEE COFFEE COFFEE

Do you have any allergies?*

Is your circulation good or bad? (bad circulation would be indicated by having cold hands or feet)*

Good
Bad
Not sure

How would you describe your energy levels day to day on a scale of 1-10?*

Very low energy 1-3
Low energy 4-5
Moderate energy 6-7
High energy levels 8-10

How many days does your menstrual cycle last for?*

Are you in the menopause*

Yes
No
Soon within 1-3 years
Pre menopause (confirmed by a doctor)

Are you struggling with any of the following menopause symptoms?*

Do you take any supplements?*

Yes
No
Not sure

Please list any supplements that you take and WHY you take them*

If you do not take any supplements simply type NONE

Do you suffer from mood swings where you lash out at others that you care about, or at yourself with self sabotaging behaviours like binge eating or drinking?*

Yes
No

Do you have children*

Yes
No

Do you have time for yourself where you relax and do nothing? (without your phone and laptop etc and including meditating, breathing, praying etc)*

Yes every day
Yes every other day
Yes perhaps once per week
No

Have you had any major changes in your lifestyle in the last 1-4 years? (moving house, babies, job changes, extreme diets, extreme exercise changes, extreme stress etc?)*

Do you smoke?*

Yes
No

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.

How much alcohol do you drink per week? Please check the box most relevant to you!*

None
1-2 units
3-4 units
5-6 units
I drink every day
I drink a large amount every weekend

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.

Please take a look at the Bristol Stool Scale (click on link at the bottom of the page) and select which type is most relevant to you*

Type 1 (very constipated)
Type 2 (slightly constipated)
Type 3 (normal)
Type 4 (normal)
Type 5 (lacking fibre)
Type 6 (inflammation)
Type 7 (inflammation)

How often do you typically pass stool?*

Every day
Every other day
2 times per week at random
Once per week
There is no pattern

Exclusion criteria for exercise referral, do you have....*

BMI <18 kg/m2 or >40 kg/m2
Any unstable medical condition
Resting blood pressure >180/110mmHg
Previous myocardial infarction
Active retinal haemorrhage
Any medical condition that the WIFI is not qualified to deal with
None of the above

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

Red flags for CRS that preclude patient from exercise referral in the case of simple mechanical back pain (SMBP) indicating the need for higher level of care/intervention. Do you have.....*

Do you have any surgery scars that might be affected by movement/exercise, if so, where? (if none, type NONE)*

Please upload a photo selfie of your face so that we might compare the condition of your skin month to month

Max. file size: 256 MB.

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

Thank you for filling out this questionnaire honestly and to the best of your knowledge. By ticking this box you are confirming that to the best of your knowledge the information that you have provided today is correct. Should you information change or if you recall anything differently, it is your responsibility to inform Rossell Fitness of this change in order to receive the most relevant service.*

Confirmation

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

Rossell Fitness Cancer Rehab Health Questionnaire