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Cancer Survivor Health History

Cancer Situation
What type(s) of cancer treatments have you received, are currently receiving, or will receive in the future? (check all that apply)

Surgery

MM slash DD slash YYYY

Chemotherapy

Chemotherapy Status
MM slash DD slash YYYY

Radiation

Immunotherapy Status
MM slash DD slash YYYY

Immunotherapy

Radiation Status
MM slash DD slash YYYY

Medical History

Past medical symptoms
Check all that apply if a result of cancer/treatment
Present symptoms
Check all that apply
Is this symptom(s) related to cancer/cancer treatments?

Hospitalization History

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Home Lifestyle and Exercise Activity

Do you have difficulty performing any of the following activities?
Did the difficulty begin before or after treatment?
Do you anticipate any barriers to starting an exercise program?
Do you have any specific cancer-related concerns about exercise?

Fatigue Inventory

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Not at allBrief part of the dayPart of the dayMost of the dayThe entire day
Cardiovascular Risk Stratification Please indicate if you are experiencing or have experienced any of the following (check all that apply)
Please indicate if you have additionally experienced any of the following