Welcome to RENEW! We are really excited to have you on board.

Before you start, we need to know a bit more about you — the kind of things you can do, the things you want to be able to do and any limitations we need to know about to make sure that we can help you reach your goals and feel great doing it.

We also want to find out the reasons for you getting involved and see how it makes a difference to your life. This information will ensure RENEW is helpful to as many people as possible who are living with cancer. Please complete this initial questionnaire, and a post-programme questionnaire after your 12 weeks, to give us feedback.

Please answer as much and as honestly as you can. If you are unsure or have any questions, please contact Jemima (renew@trekstock.com), your GP or oncologist.


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We are also evaluating the programme to ensure that it is as effective as possible. Kate, our programme evaluator, would love to get in touch to let you know about this evaluation and how you can get involved. Please tick yes to indicate that you are happy for her to get in touch with you. *

     
 
Personal Details

 
Title *

 
Full name *

 
Age *

 
Date of birth *

 
Ethnicity

 
Address *

 
Postcode

 
Emergency contact name

 
Emergency contact relationship to you

 
Emergency contact phone number

 
Health Information

 
Cancer type

 
Cancer stage

 
Current treatment status


 
Current physical activity levels

 
During a typical 7-day period, in your leisure time how often do you engage in regular activity long enough to work up a sweat (heart beats rapidly)?


 
What kind of exercise do you prefer? (tick all that apply): *


 
Anything else you want to tell us about the kind of exercise you prefer

 
From the list below, choose any factors that help motivate you to exercise. *


 
What do you find makes it harder for you to exercise?

 
During a typical 7-day period, how many times on the average do you do the following kinds of activity for more than 15 minutes during your free time?

 
Strenuous exercise (heart beats rapidly) - e.g., running, jogging, football, rugby, cycling.

 
Times per week

 
Duration of each session

 
Type of exercise

 
Moderate Exercise (not exhausting)- e.g., fast walking, easy cycling, easy swimming, tennis.

 
Times per week

 
Duration of each session

 
Type of exercise

 
Mild Exercise (minimal effort required) - e.g., easy walking, yoga, golf.

 
Times per week

 
Type of exercise

 
Duration of each session

 
The last seven days

 
How optimistic do you feel about the future?

 
How energetic do you feel?

 
How clearly do you feel able to think?

 
How do you feel about what your body looks like?

 
How in control of your life do you feel?

 
How able are you to relax?

 
You and your body

 
Which of the following statements best describe how you feel? (tick as many as you like) *


 
Friends and Family

 
Which of the following statements best describe how you feel? (tick as many as you like) *


 
Goals for the programme

 
As of now, how important do you think it is to make changes to your physical activity? *

 
As of now, how confident do you feel to be able to change your physical activity? *

 
What do you hope to achieve as a result of participating in this programme? *


 
What are the most important goals for you? *

Choose up to three goals that apply

 
Health Information

 
Past/Current treatments

Please list any treatments that you have had/are having (please include chemotherapy, radiotherapy and surgery, location and dates of treatment)
 
Medications *

Please list any prescription medicines or alternative therapies you are currently taking, and any side effects of these
 
Side effects of treatment

 
Fatigue *

Feeling physically, mentally and emotionally exhausted, not always helped with sleep

 
Describe how this limits you

 
Things that help

 
Post-surgical considerations *

Any parts of your body surgically altered, unhealed wounds, or current ostomies

 
Describe how this limits you

 
Things that help

 
Sensory limitations *

Any speech or swallowing difficulties, problems with vision, balance, weakness

 
Describe how this limits you

 
Things that help

 
Cognitive dysfunction *

Memory impairment, mental fogginess, difficulty concentrating, slower processing speed

 
Describe how this limits you

 
Things that help

 
Blood abnormalities *

Include any blood results within the last three months if necessary

 
Describe how this limits you

 
Things that help

 
Lung or heart problems *

Arrhythmias (irregular heart beat), heart damage, lung/breathing problems. Include any recent tests (ECG, ECHO, lung function if necessary)

 
Describe how this limits you

 
Things that help

 
Bone metastasis *

Any cancer deposits within your bones or reason you may have early onset osteoporosis or weak bones (hormone treatment). You may require a fracture risk assessment

 
Describe how this limits you

 
Things that help

 
Lymphoedema *

Fluid builds up, such as when lymph nodes have been removed

 
Describe how this limits you

 
Things that help

 
Immune system suppression *


 
Describe how this limits you

 
Things that help

 
Pain *


 
Describe how this limits you

 
Things that help

 
Nausea/vomiting *


 
Describe how this limits you

 
Things that help

 
Any other medical concerns that should be known (e.g. pregnancy, other illness/injuries)

 
Health Information

How do you currently seek out health information?

Thank you for completing the pre-questionnaire for our renew exercise programme!



We will get in contact with you soon to get you started.
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