First Name
* must provide value
Last Name
* must provide value
Phone Number
* must provide value
Email Address
* must provide value
Preferred Contact Method
* must provide value
phone
email
UMass Referral?
* must provide value
Yes
No
Has your doctor ever said that you have a heart condition or high blood pressure?
* must provide value
YES
NO
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
* must provide value
YES
NO
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
* must provide value
YES
NO
Have you ever been diagnosed with another chronic medical condition (e.g. diabetes, pulmonary disease, etc.)?
* must provide value
YES
NO
Are you currently taking prescribed medications for a chronic medical condition?
* must provide value
YES
NO
In the past 12 months have you had a bone, joint, muscle, ligament, or tendon problem that could be made worse by becoming more physically active? (Please answer NO if you had a problem in the past, but it does NOT limit your current ability to be physically active)
* must provide value
YES
NO
Has your doctor recommended you only perform exercise (or physical activity) when supervised by a medical or exercise professional?
* must provide value
YES
NO
Have you ever been diagnosed with cancer?
* must provide value
YES
NO
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
* must provide value
YES
NO
Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?
* must provide value
YES
NO
Have you ever had a major lung or abdominal surgery?
* must provide value
YES
NO
Do you use an ostomy bag?
* must provide value
YES
NO
Would you rate your average daily fatigue as a 7 out of 10 OR GREATER on a scale of 0 to 10? (0=no fatigue, and 10= worst fatigue you can imagine)
* must provide value
YES
NO
Have you been diagnosed with ataxia (i.e. lack of muscle control or coordination of voluntary movements)?
* must provide value
YES
NO
Have you received therapy for lymphedema in the last 3 months?
* must provide value
YES
NO
In the past 6 months, have you experienced an increase in arm or leg circumference that may be related to lymphedema?
* must provide value
YES
NO
Have you ever been told that your cancer has spread (metastasized) to your bones or brain?
* must provide value
YES
NO
Have you lost 5 or more lbs in the last month without intending to?
* must provide value
YES
NO
What was your primary cancer diagnosis?
* must provide value
Do you have Arthritis, Osteoporosis, or Back problems?
* must provide value
YES
NO
Do you have difficulty controlling your orthopedic condition (arthritis, osteoporosis, or back problems) with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Have you experienced any of the following conditions?
* must provide value
YES
NO
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
* must provide value
YES
NO
Do you have Heart Disease or a Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm.
* must provide value
YES
NO
Do you have difficulty controlling your heart/cardiovascular condition with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Do you have an irregular heart beat (e.g., atrial fibrillation, premature ventricular contraction) that requires medical management?
* must provide value
YES
NO
Do you have chronic heart failure?
* must provide value
YES
NO
Do you have diagnosed coronary artery (cardiovascular) disease AND have not participated in regular physical activity in the last 2 months?
* must provide value
YES
NO
Do you have high blood pressure?
* must provide value
YES
NO
Do you have difficulty controlling your high blood pressure with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?
YES
NO
Have you been diagnosed with a metabolic condition such as Type I or 2 Diabetes or Pre-Diabetes?
* must provide value
YES
NO
Do you often have difficulty controlling blood sugar levels with foods, medications, or other physician--prescribed therapies
* must provide value
YES
NO
Do you often suffer from signs and symptoms of low blood sugar following exercise AND/OR during activities of daily living (e.g. shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness)?
* must provide value
YES
NO
Do you have any signs or symptoms of diabetes complications (e.g. heart or vascular disease, complications affecting your eyes or kidneys, OR the sensation in your toes and feet)?
* must provide value
YES
NO
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
* must provide value
YES
NO
Are you planning to engage in high intensity exercise (compared to your current activity levels) in the near future?
* must provide value
YES
NO
Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, and Down Syndrome.
* must provide value
YES
NO
Do you have difficulty controlling your mental health condition with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Do you have Down Syndrome AND back problems affecting nerves or muscles?
* must provide value
YES
NO
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, and Pulmonary High Blood Pressure.
* must provide value
YES
NO
Do you have difficulty controlling your respiratory condition with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
* must provide value
YES
NO
If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?
* must provide value
YES
NO
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
* must provide value
YES
NO
Do you have a Spinal Cord Injury? This includes tetraplegia and paraplegia.
* must provide value
YES
NO
Do you have difficulty controlling your spinal cord condition with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
* must provide value
YES
NO
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
* must provide value
YES
NO
Have you had a stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event.
* must provide value
YES
NO
Do you have difficulty controlling your stroke-related condition with medications or other physician-prescribed therapies?
* must provide value
YES
NO
Do you have an impairment in walking or mobility?
* must provide value
YES
NO
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
* must provide value
YES
NO
Do you have any other medical conditions not discussed in this survey?
* must provide value
YES
NO
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
* must provide value
YES
NO
Have you ever been diagnosed with any of the following?
* must provide value
YES
NO
Do you currently live with two or more medical conditions?
* must provide value
YES
NO
Please list your medical condition(s) and any related medications here.
* must provide value
Thank you for answering these questions about your medical history. We look forward to your participation in Fit Cancer!
Thank you for answering these questions about your medical history. We look forward to your participation in Fit Cancer!
