Please fill out the following referral form for the CanWell - Cancer Exercise & Education Program. Patient Address Address City/Town ZIP/Postal Code Patient Phone Number Patient Birthday Patient Name Cancer Type Date of Diagnosis Treatment Treatment - None -SurgeryChemotherapyRadiationImmunotherapyOther… Enter other… Treatment Ended Date Relevant Medical History Relevant Medical History - None -DiabetesPADCardiacHypertensionOther… Enter other… Is patient on Beta-Blocker Medication - None -YesNo Recommended to Measure Blood Glucose Pre and Post Excercise - None -YesNo Risk Factors / Side Effects Risk Factors / Side Effects - None -Skin ProblemsPICC LineAphasiaIncontinenceSpinal Cord CompressionBack PainOther Pain... Enter other pain… Exercise Contradictions, Limitations or Restrictions - None -Surgical PrecautionLifting RestrictionBone Metastatic DiseaseLow Blood CountsNeuropathy Financial Assistance Required Other Notes Name of Physician Physician Phone Today's Date Leave this field blank This information contained within this referral has been discussed with the patient.
Patient Address Address City/Town ZIP/Postal Code Patient Phone Number Patient Birthday Patient Name Cancer Type Date of Diagnosis Treatment Treatment - None -SurgeryChemotherapyRadiationImmunotherapyOther… Enter other… Treatment Ended Date Relevant Medical History Relevant Medical History - None -DiabetesPADCardiacHypertensionOther… Enter other… Is patient on Beta-Blocker Medication - None -YesNo Recommended to Measure Blood Glucose Pre and Post Excercise - None -YesNo Risk Factors / Side Effects Risk Factors / Side Effects - None -Skin ProblemsPICC LineAphasiaIncontinenceSpinal Cord CompressionBack PainOther Pain... Enter other pain… Exercise Contradictions, Limitations or Restrictions - None -Surgical PrecautionLifting RestrictionBone Metastatic DiseaseLow Blood CountsNeuropathy Financial Assistance Required Other Notes Name of Physician Physician Phone Today's Date Leave this field blank
