Exercise referral and cancer rehabilitation in Wirral supporting strength, recovery and managing health conditions through mo

Consultation form

Please fill in all fields - If not applicable type (N/A)

First name

Last name

Phone

Birthday

Day

Month

Year

Address

Occupation:

Height

Weight

What service type

Cancer Rehab

Exercise Referral

1-2-1 Coaching

GP Name & Surgery:

Oncology Team / Consultant (if applicable):

Emergency Contact Name & Number:

Cancer & Treatment Information

Type of Cancer Diagnosis:

Date of Diagnosis:

Current Stage of Care: 

Pre-treatment

During treatment

Post-treatment

Long-term remission

If "Other" please specify

Are you currently undergoing treatment?

Yes

Are there any side effects we should be aware of?

Have you received medical clearance to participate in exercise?

Yes

Other (please specify)

Additional precautions or clinical notes:

Exercise Referral Medical Conditions

Medical Screening (PAR-Q)

Has a doctor ever advised you to exercise only under medical supervision?

Yes

Do you experience chest pain during activity?

Yes

Do you lose balance due to dizziness or blackouts?

Yes

Do you have bone or joint issues that may worsen with exercise?

Yes

Are you currently prescribed medication for heart or blood pressure conditions?

Yes

Is there any other reason you should not participate in physical activity?

Yes

If YES to any, please provide details:

General Medical History

Do you have any additional diagnosed conditions? (Please list)

Current medications:

Any allergies or adverse reactions:

Recent surgeries or hospitalisations:

Lifestyle & Wellbeing

Current activity level: 

Sedentary

Lightly Active 

Moderately Active

Do you currently exercise? If yes, what type and how often?

Average sleep per night:

Hydration level

Poor

Average

Good

Diet & Nutrition

Poor

Average

Good

Do You Smoke

Yes

Alcohol units PW:

Caffeine intake

Main challenges currently:

Your Goals

What would you like to achieve through 1-2-1 coaching, Cancer Rehabilitation Or Exercise Referral?

What does “feeling stronger” mean to you personally?

Informed Consent

I understand that:

• I am voluntarily participating in a structured 1-2-1 Coaching, Cancer Rehabilitation & Exercise Referral programme.

• The programme is tailored to my medical history, treatment stage, and current ability.

• Exercise may include gentle cardiovascular, strength, mobility and functional training.

• Physical activity carries inherent risks, though sessions are designed to minimise risk.

• I will inform my instructor of any changes in symptoms, treatment, or health status.

• I may stop exercise at any time.

• I am responsible for communicating discomfort, pain, dizziness, or unusual symptoms immediately.

In the event of a medical emergency, I authorise appropriate action to be taken.

I understand

Confidentiality

All personal and medical information will be treated confidentially and handled in accordance with data protection regulations.

Photo & Media Consent

I give permission for Earthey Coaching to use photographs or video footage for promotional purposes.

Yes

I understand I can withdraw this consent in writing at any time.

Declaration

I confirm that the information provided is accurate to the best of my knowledge and that I have read and understood this form.