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Oncology rehabilitation registration

Home/Oncology rehabilitation registration

Oncology rehabilitation registrationJohn Isaacson2026-08-21T08:36:42+01:00

Oncology Rehabilitation Registration

Personal Details

Full Name:

Date of Birth:

Address:

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:

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:

Ready to Move and Feel Better?

Book a 1:1 or group Pilates class with our specialist Clinical Pilates Instructors. In-studio across London and Norfolk, or online.

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Physio-led Pilates studios across London, Norfolk and online.

0203 764 5668 info@complete-pilates.co.uk Book Now

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