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Forms Directory
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Cancer Survivor Health History
Cancer Survivor Health History
First Name
(Required)
Last Name
(Required)
Email
(Required)
Cancer Situation
I am the person with cancer
A friend/family member has cancer
What type(s) of cancer treatments have you received, are currently receiving, or will receive in the future? (check all that apply)
Surgery
Chemotherapy
Radiation
Immunotherapy
Medication
Surgery
Date of Surgery
MM slash DD slash YYYY
List any persistent side effects from surgery
Chemotherapy
Chemotherapy Status
Pre-treatment
Current
Post-treatment
Date of Chemotherapy Completion
MM slash DD slash YYYY
List any persistent side effects from chemotherapy
Radiation
Immunotherapy Status
Pre-treatment
Current
Post-treatment
Date of Radiation Completion
MM slash DD slash YYYY
List any persistent side effects from radiation
Immunotherapy
Radiation Status
Pre-treatment
Current
Post-treatment
Date of Immunotherapy Completion
MM slash DD slash YYYY
List any persistent side effects from immunotherapy
List any medications prescribes as part of treatment (please include medication name, dosage, date started, and what it is prescribed for)
List any persistent side effects from medications related to treatment
Medical History
Past medical symptoms
Fatigue
Depression
Anxiety
Sleep Issues
Weight Change
Appetite Change
Joint Issues
Pain
Shortness of Breath
Muscle Weakness
Fractures
Lymphedema
Neuropathy
Edema
Other
Check all that apply if a result of cancer/treatment
Present symptoms
Rheumatic fever/heart murmur
Chest discomfort
Heart abnormalities, racing/skipping beats
Abnormal ECG
Coughing up blood
Stomach/intestinal problems
Anemia
Stroke
Migraine/recurrent headaches
Back/neck pain/injuries
Foot/ankle problems
Knee/hip problems
Thyroid problems
Lung disease
Chronic/recurrent cough
Disease of arteries
Varicose veins
Arthritis
Epilepsy
Vision/hearing problems
Check all that apply
Is this symptom(s) related to cancer/cancer treatments?
Yes
No
Please explain any additional details and dates for each box checked(including date of occurrence)
Please list all current medications NOT related to cancer or cancer treatment. Be sure to add medication name, dosage, date started and what it has been prescribed for
Please list any additional medical concerns of complications NOT related to cancer
Hospitalization History
Most recent date of hospitalization/surgery
MM slash DD slash YYYY
Hospitalization and/or surgery (starting with most recent) for:
Second most recent date of hospitalization and/or surgery
MM slash DD slash YYYY
Hospitalization and/or surgery for:
Additional date of hospitalization/surgery
MM slash DD slash YYYY
Please list all current medications related to cancer treatment. Be sure to include medication name, dosage, date started and what it has been prescibed for
Home Lifestyle and Exercise Activity
Do you have difficulty performing any of the following activities?
Opening jars/doorknobs
Clasping clothing
Making a bed
Driving
Routine yard work
Putting groceries/dishes away
Carrying groceries/laundry
Walking up/down stairs
Lifting children
Removing laundry from washer/dryer
Did the difficulty begin before or after treatment?
Before
After
N/A
If known, explain the cause of the difficulty
How many days per week do you exercise regularly?
0
1
2
3
4
5
6
7
Other
What exercises do you participate in regularly?
How many minutes do you spend exercising at one time?
10 minutes
20 minutes
30 minutes
45 minutes
60 minutes
Other
If you chose other, how many minutes do you spend exercising at one time?
What would you consider your exercise to be (check one)
Light
Moderate
Vigorous
What activities do you enjoy most?
What is your main goal related to starting an exercise program?
Do you anticipate any barriers to starting an exercise program?
Lack of time
Weather
Lack of enjoyment from exercise
Fatigue or feeling unwell
Lack of self-discipline
Lack of equipment
Other
You chose other, please list additional barriers
Do you have any specific cancer-related concerns about exercise?
Type of exercise that is safe during or following cancer treatment
Risk of developing lymphedema
risk of infection at the fitness center or public facility
Knowledge of exercise staff related to working with cancer survivors
Other
You chose other, please list additional cancer-related concerns about exercise
Fatigue Inventory
Rate your level of fatigue on the day you felt most fatigued during the past week. (1 being the least and 10 being the worst)
1
2
3
4
5
6
7
8
9
10
Rate your level of fatigue on the day you felt the least fatigued during the past week.
1
2
3
4
5
6
7
8
9
10
Rate your level of fatigue on the average during the past week.
1
2
3
4
5
6
7
8
9
10
Rate your level of fatigue right now.
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your general level of activity.
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your ability to bathe and dress yourself.
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your normal work activity (both outside the home and housework)
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your ability to concentrate
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your relations with other people
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, interfered with your enjoyment of life
1
2
3
4
5
6
7
8
9
10
Rate how much, in the past week, fatigue interfered with your mood
1
2
3
4
5
6
7
8
9
10
Indicate how many days, in the past week, you felt fatigued for any part of the day
0
1
2
3
4
5
6
7
8
9
10
Rate how much of the day, on average, you felt fatigued in the past week
Not at all
Brief part of the day
Part of the day
Most of the day
The entire day
Indicate which of the following best describes the daily pattern of your fatigue in the past week
Not at all fatigued
Worse in the morning
Worse in the afternoon
Worse in the evening
No consistent daily pattern of fatigue
Cardiovascular Risk Stratification Please indicate if you are experiencing or have experienced any of the following (check all that apply)
Heart attack
Coronary angioplasty (PTCA)
Heart surgery
Heart valve disease
Congenital heart disease
Cardiac catheterization
Heart failure
Pacemaker/implantable cardiac defibrillator/rhythm disturbance
Experience chest comfort with exertion
Experience unreasonable breathlessness
Diabetes
Asthma or other lung disease
Burning or cramping sensation in lower legs when walking a short distance
Musculoskeletal problems that limit your physical activity
Pregnant
Dizziness, fainting or blackouts
Take heart medication
Have exercise safety concerns
Take prescription medications
Please indicate if you have additionally experienced any of the following
You are a male over 45 years of age
You are a female over 55, have had a hysterectom,y or are mostmenopausal
You are 20 lbs. or more overweight
You smoke, or quit smoking in the past 6 months
You take blood pressure medication
Your blood cholesterol is at or above 200 ml/dl
You have a blood relative who had a heart attack or heart surgery before age 55 (father/brother or 65 (mother/sister)
You are physically inactive (less than 30 minutes of physical activity at least 3 days per week)
None of the above
Δ