Life With Cancer Program Exercise Registration Form printable pdf download

Life With Cancer Program Exercise Registration Form

Exercise Registration Form

Class Title: _____________________________________________ Date: ___________________________

Name ___________________________________________

____________________________________

Last

First

Address ________________________________________________________________________________

Street

City

State

Zip Code

Telephone H _______________________ Cell _________________________W______________________

Email _____________________________________________

Date of Birth __________________

Height___________

Weight___________

Sex_______

Emergency Contact ________________________________________ _________________________

Name

Telephone

Physician Contact _________________________________________ _________________________

Name

Telephone

ADVISORY AND PERSONAL ASSESSMENT

Participation in any exercise program may increase your risk of injury. Such risks can include, but are not limited to permanent

injury or death from falls, collision with others, the exercise room and equipment conditions, and your physical status. The

following medical conditions may affect your participation in this program and increase your risk. Please check accordingly and

explain specifics. Consultation with your physician is recommended for your participation in this exercise program.

Medical Condition

If Yes, please give specifics

Date of diagnosis:

Cancer Diagnosis (Type?)

Currently undergoing treatment for cancer (What kind?)

Surgery within the past 6 months (Location?)

High blood pressure

Heart condition

Fainting tendency or dizziness

Chest pain or breathlessness during and/or after

mild exertion

Bone, joint, muscle, tendon problems (e.g. arthritis, osteo-

porosis, tendonitis or joint replacement of hip, knee, shoulder)

Life With Cancer Program Exercise Registration Form