Skip to content
Search for:
1:1 Pilates
Pilates Classes for Beginners
Pregnancy Pilates Classes
Postnatal Pilates Classes
Rehab Pilates Classes
Pilates for cancer rehabilitation
New clients
Online Pilates
On Demand
Online Pilates Classes
Group Pilates
About
Meet the Team
Videos
Blogs
Testimonials
Locations
The City EC3M
Chelsea SW10
Pilates Classes in Angel, Islington
Online
Prices
Contact Us
BOOK NOW
Get in touch
Search for:
Oncology rehabilitation registration
John Isaacson
2021-03-08T10:04:31+00:00
Oncology rehabilitation registration
Personal Details
Full Name:
First
Last
Date of Birth:
MM slash DD slash YYYY
Address:
Street Address
Address Line 2
City
Post Code
Email:
Phone:
Sex
Male
Female
Would rather not to say
Occupation:
How did you hear about Complete Pilates:
GP name:
GP Practice:
Surgeon:
Hospital:
Cancer type:
Grade:
Date of diagnosis:
MM slash DD slash YYYY
Cancer Treatments
Types of surgery
Partial mastectomy
Mastectomy
Axillary node dissection
Wide local excision
Brain surgery
Colorectal surgery
Head and neck surgery
Oophorectomy
Breast reconstruction
Type and date:
Untitled
Right
Left
Bilateral
Lymph node removal:
Lymph node removal
Number of nodes removed:
Right
Left
Other surgery
Other surgery
Type and date:
Adjunctive treatment
Hormone therapy:
Yes
No
To come
Chemotherapy:
Yes
No
To come
Radiation Therapy:
Yes
No
To come
​Immunotherapy:
Yes
No
To come
Other :
Current medications:
Side effects from medication:
Ongoing plan for cancer treatment:
Are you experiencing post-op pain?
Yes
No
Pain intensity: (0 = no pain, 10 = worse pain ever):
0
1
2
3
4
5
6
7
8
9
10
Body site:
Aggravating factors:
Other musculoskeletal issues:
Please list any current sites of pain and whether the pain is constant
1st sites of pain
1st Constant pain
Constant pain
1st sites of pain
2nd Constant pain
Constant pain
3rd sites of pain
3rd Constant pain
Constant pain
Do you have any other medical conditions?
Have you experienced Lymphoedema:
Yes
No
Unsure
Seeing specialist
Functional limitations:
Home
Work
Activity and fatigue
Exercise prior to cancer diagnosis:
Current level of physical activity:
No physical activity
Limited physical activity
Regular physical activity
Average time spent exercising each week:
Fatigue levels:
1-3 (Mild)
4-6 (Moderate)
7-10 (Severe)
Rehabilitation
Phase of rehabilitation:
Pre-op
Post-op
During treatment
Survivorship
What are your goals:
Phone
This field is for validation purposes and should be left unchanged.
Go to Top
