LIVESTRONG at the YMCA
Intake Form
Click this dropdown box to complete LIVESTRONG Enrollment Form. Estimated time to complete 5-10 minutes.
Registration Date
-
Month
-
Day
Year
Date
YMCA Branch Preference
Please Select
NorthWest Family YMCA
Ballentine YMCA
Downtown YMCA
Jeep Rogers YMCA
Orangeburg YMCA
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sex:
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Contact Method
Email
Home Phone
Mobile- Cell
Mobile- Text
Other
How did you hear about the program?
Current/former Program Participant
Doctor/Other Health Care Professional
Employer
Family/Friend/Word of Mouth
Health Insurance Company
Media/Marketing
Screening Event/Health Fair
Y Staff Member/Volunteer
Other
What is your highest level of education?
Less than high school
High school diploma or GED
Associate degree
Bachelor's degree
Master's degree
Doctorate
Professional degree
Other
What is your race? (Check all that apply.)
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
A race not listed here.
Prefer not to answer.
Are you of Hispanic, Latino(a), or Spanish Origin?
Yes
No
Prefer not to answer.
Are you a member of the Y?
Yes
No
Employer Name:
HEALTH INFORMATION
All information provided will be held confidential under HIPAA Laws. Please fill out the form to your best of ability so that your Instructor for the LIVESTRONG class can prescribe a safe and effective workout according to your Medical History and current symptoms.
Where were you treated?
Physician name:
First Name
Last Name
Have you ever had any of the following health conditions (Select all that apply) ?
Pulmonary (lung) problem
Heart problems or surgery
Diabetes
Altered heart rate
Dizziness or fainting (unrelated to cancer treatment)
Chest, neck or arm pain
Pain or cramping in legs while walking
Short-term weakness on one side of the body
Elevated blood pressure
Low blood pressure
High cholesterol
Smoker or previous smoker
Arthritis
Other
If you checked the box for a condition above, please describe briefly the condition and it's effect on your life at this present time:
Type of Cancer:
Bladder
Bone
Brain
Breast
Cervical
Colon and Rectal
Endometrial
Esophageal
Head and Neck
Kidney (renal cell)
Leukemia
Liver
Lung
Lymphoma
Myeloma
Oral
Ovarian
Pancreatic
Prostate
Rectal
Melanoma
Skin (Non Melanoma)
Stomach (gastric)
Testicular
Thyroid
Uterine
Other
Cancer Diagnosis Date (MM/YYYY)
Surgery?
No
If Yes, date of most recent surgery:
Chemotherapy?
No
If yes, date of last treatment:
Radiation?
No
If Yes, date of last treatment:
Do you have an implemented port or Central Venous Access Catheter?
No
If yes, please specify location:
Are you experiencing peripheral neuropathy (i.e. tingling/loss of sensation in your fingers and/or toes)?
No
If yes, specify location:
Has the cancer spread to any bones?
No
If yes, please describe where:
Have you had any lymph nodes removed?
Yes
No
Where have you had lymph node involvement?
Head and Neck
Left Upper Extremity
Left Lower Extremity
Right Upper Extremity
Right Lower Extremity
Check all that are true:
I have been DIAGNOSED with Lymphedema.
I am currently experiencing STIFFNESS or LOSS OF RANGE OF MOTION in the area that the lymph nodes have been removed.
I am currently experiencing PAIN or DISCOMFORT in the area that the lymph nodes have been removed.
Are there any other medical illnesses, injury, or issues (physical or psychological) we should be aware of?
No
If yes, please explain:
List current medications, including vitamins and over the counter (If not applicable, record 0)
Describe your health at the present time:
Poor
Fair
Good
Very good
Excellent
Do you participate in exercise regularly?
No
Yes
Please describe the FREQUENCY of your exercise:
Daily
2-6 times weekly
Once a week
Less than once a week
Monthly
Please describe the INTENSITY of your exercise:
Light
Moderate
Heavy
Please list the TYPES of exercise you participate in regularly
Do you have any physical limitations that restrict your daily living activities or ability to exercise?
No
If yes, please explain:
Are there any limitations since your cancer diagnosis?
No
If yes, please explain:
If you're working, what is your level of activity at work:
Sedentary
Light
Moderate
Vigorous
Not relavent
If you're not working, when did you stop?
-
Month
-
Day
Year
Date
Describe your past experience with resistance training and aerobic training
What expectations do you have from this program?
Do you have any concerns about starting this exercise program?
SELECT ALL the times that you could attend the 90-minute class. Example of class times are: Mon/Wed from 2-330 or Tues/Thurs from 6-730
Monday
Tuesday
Wednesday
Thursday
Friday
10-1130
2-330
3-430
6-730
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YMCA STAFF ONLY
Participant Contact Log
Patient Contact Log & Enrollment Status
FOR YMCA STAFF ONLY
Patient is
Contacted
Enrolled
Waiting on Medical Clearance
Waitlisted
Declined
Withdrew
Completed
Patient Contact Log/Enrollment Status
Cohort Enrolled Into
Please Select
Session #1 - 9/28/22 Ballentine 11:30a
Session #2 - 1/28/23 NW
Session #3 - 5/29/23 BT
Session #4 - 9/25/23 NW
Session #5 - 2/19/24 Downtown
Session #6 - 2/19/24 Jeep Rogers
Session #7 - 3/18/24 NW
Session #8 - 9/23/24 BT
Session #9 - 9/23/24 Jeep
Session #10 - 9/23/24 Downtown
Session #11 - 10/1/24 Orangeburg
YMCA Association
Please Select
Cherokee County Family YMCA
Columbia YMCA
Foothills Area YMCA
Greenville YMCA
Lakelands Region YMCA
Pickens County YMCA
Summerville Family YMCA
Sumter YMCA
Upper Pee Dee YMCA
YMCA of Upper Palmetto
Branch
If a nonmember, did the participant join the YMCA at the end?
Yes
No
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Program Attendance & Goal Tracker
STAFF ONLY
Instructor(s) Assigned to Lead Cohort
Please Select
Darlynn
Craig
Kate
Victoria
Sharon
Kirsten
Barbara
J'aimee
Instructor(s) Assigned to Lead Cohort
Please Select
Darlynn
Craig
Kate
Victoria
Sharon
Kirsten
Barbara
J'aimee
Date Cohort Started
-
Month
-
Day
Year
Date
Date Cohort Finished
-
Month
-
Day
Year
Date
Attendance Tracker
Date
Check Box if they Attended
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12
Session 13
Session 14
Session 15
Session 16
Session 17
Session 18
Session 19
Session 20
Session 21
Session 22
Session 23
Session 24
Progress Notes
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PROMIS-29
BASELINE ASSESSMENT
Assessment Date (MM/DD/YY)
/
Month
/
Day
Year
Date
Person Completing Form
First Name
Last Name
Please respond to each question or statement by
marking one box per row.
PHYSICAL FUNCTION
Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do
Do chores such as vacuuming or yard work?
Go up and down stairs at a normal pace?
Go for a walk of at least 15 minutes?
Run errands and shop?
DO NOT MANIPULATE: Baseline - Physical
ANXIETY
In the past 7 days
Never
Rarely
Sometimes
Often
Always
I felt fearful
I found it hard to focus on anything other than my 6 anxiety
My worries overwhelmed me
I felt uneasy
DO NOT MANIPULATE: Baseline - Anxiety
DEPRESSION
In the past 7 days
Never
Rarely
Sometimes
Often
Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
DO NOT MANIPULATE: Baseline - Depression
FATIGUE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel fatigued
I have trouble starting things because I am tired
How run-down do you feel on average?
How fatigued did you feel on average?
DO NOT MANIPULATE: Baseline - Fatigue
SLEEP DISTURBANCE
In the last 7 days,
Very poor
Poor
Fair
Good
Very Good
My sleep quality was
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very Much
My sleep was refreshing
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I had a problem with my sleep
I had difficulty falling asleep
DO NOT MANIPULATE: Baseline - Sleep
SATISFACTION WITH SOCIAL ROLE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I am satisfied with how much work I can do (including work from home)
I am satisfied with my ability to do regular personal and household responsibilities
I am satisfied with my ability to perform my daily routines
I am satisfied with my ability to participate in social activites
DO NOT MANIPULATE: Baseline - Social Satisfaction
PAIN INTERFERENCE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
How much did pain interfere with your day to activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to
How much did pain interfere with your
DO NOT MANIPULATE: Baseline - Pain Interference
PAIN INTENSITY
How would you rate your pain on average?
0 - no Pain
1
2
3
4
5
6
7
8
9
10
DO NOT MANIPULATE: Baseline - Pain Intensity
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Functional Assessment
BASELINE Report
Person Completing Form
First Name
Last Name
Assessment Date (DD/MM/YYYY):
AEROBIC FUNCTION
6 Minute Walk Test
Beginning Heart Rate (Ex: 60)
Ending Heart Rate (Ex: 120)
Total Number of Laps (full and partial) (Ex: 12.5) (Pre)
Total Distance in Meters (Ex: 300) (pre)
Beginning RPE
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
End RPE:
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Comments:
STRENGTH TESTING
Leg Press 1 Rep Max (ex: 80) (Pre)
Comments
Chest Press 1 Rep Max (ex: 80) (Pre)
Comments
FLEXIBILITY AND BALANCE
Back Scratch Right Up (Ex: -1) (pre)
Back Scratch Left Up (Ex: 1) (pre)
Arm Reach Total Distance in Inches (Ex: 12) (Subtract Beginning from End Reach)
Single Leg Stance (Ex: 20.25) (Right Leg)
Single Leg Stance (Ex: 30.45) (Left Leg)
Comments
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PROMIS-29
Post Program Assessment
Assessment Date
-
Month
-
Day
Year
Date
Please respond to each question or statement by
marking one box per row.
PHYSICAL FUNCTION
Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do
Do chores such as vacuuming or yard work?
Go up and down stairs at a normal pace?
Go for a walk of at least 15 minutes?
Run errands and shop?
Post Assessment - Physical
ANXIETY
In the past 7 days
Never
Rarely
Sometimes
Often
Always
I felt fearful
I found it hard to focus on anything other than my 6 anxiety
My worries overwhelmed me
I felt uneasy
Post - Anxiety
DEPRESSION
In the past 7 days
Never
Rarely
Sometimes
Often
Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
Post - Depression
FATIGUE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I feel fatigued
I have trouble starting things because I am tired
How run-down do you feel on average?
How fatigued did you feel on average?
Post - Fatigue
SLEEP DISTURBANCE
In the past 7 days,
Very Poor
Poor
Fair
Good
Very Good
My sleep quality was
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very Much
My sleep was refreshing
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I had a problem with my sleep
I had difficulty falling asleep
Post -Sleep Disturbance
SATISFACTION WITH SOCIAL ROLE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
I am satisfied with how much work I can do (including work from home)
I am satisfied with my ability to do regular personal and household responsibilities
I am satisfied with my ability to perform my daily routines
I am satisfied with my ability to participate in social activites
Post -Social Role Satisfaction
PAIN INTERFERENCE
In the past 7 days
Not at all
A little bit
Somewhat
Quite a bit
Very much
How much did pain interfere with your day to activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to
How much did pain interfere with your
Post - Pain Interference
PAIN INTENSITY
How would you rate your pain on average?
0 - No pain
1
2
3
4
5
6
7
8
9
10
Post - Pain Intensity
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Functional Assessment
Post Program Report
Assessment Date (DD/MM/YYYY):
AEROBIC FUNCTION
6 Minute Walk Test
Beginning HR (Ex: 60) (post)
Ending HR (Ex: 120) (post)
Total Number of Laps (Ex: 12.25) (full and partial) (post)
Total Distance in Meters (Ex: 402.66) (post)
Beginning RPE
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
End RPE:
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Comments:
STRENGTH TESTING
Leg Press 1 Rep Max (ex: 80) (Post)
Chest Press 1 Rep Max (ex: 80) (Post)
Comments
FLEXIBILITY AND BALANCE
Back Scratch (Right Up) (Ex: 2) (Post)
Back Scratch (Left Up) (Ex: 4) (Post)
Arm Reach Test Total Distance (Ex: 10.25) (Post)
Single Leg Stance (Left Leg) (ex: 45.60) (post)
Single Leg Stance (Right Leg) (ex: 55.60) (post)
Comments
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Promis-29 Progress Report
DO NOT MANIPULATE FIELDS BELOW
Physical Function % Change
Anxiety % change
Depression % change
Fatigue % change
Sleep % change
Social Role Satisfaction % change
Pain Interference % change
Pain Intensity % change
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Functional Assessment Progress Report
DO NOT MANIPULATE FIELDS BELOW
6 Minute Walk Total Distance - % of Change
Chest Press % of Change
Leg Press % of Change
Right Back Scratch % of Change
Left Back Scratch % of Change
Arm Reach % of Change
Balance Right % of Change
Balance Left % of Change
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Attendance Report
Total # of Classes Attended
Should be Empty: