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Cancer United, Cancer Support, Cancer Fitness, Cancer Exercise, Cancer West Sussex, CUFitterXtra, CUFitter Xtra, Fitness Classes, Charity, Cancer Charity, UK Cancer Charity Cancer United

Welcome to CUFitterXtra - an online fitness programme for people affected by cancer.

Which online classes are you suitable for?

Fill in this free no obligation physical activity risk questionnaire to find out which CUFitterXtra class you are recommended for by our cancer specialist instructors

Full Name

Date of Birth

Address

Gender

Ethnicity

Phone

Email Address

Disability *

Yes

1. Have you been diagnosed with a heart condition? Or do you have an irregular heart beat? *

Yes

2. Do you have chest pain or discomfort when you are physically active? Do you have this pain even when you are not exercising? *

Yes

3. Do you have high or low blood pressure? *

Yes

4. Do you ever become dizzy, lose your balance or lose consciousness? *

Yes

5. During the past year, have you fallen over more than twice? *

Yes

6. Do you have problems with your bones or joints? If so, does this problem become worse when you exercise? *

Yes

Do you have any of the following? Please tick the appropriate box

Please tick the box

Diabetes

High Cholesterol

COPD

Asthma

Anxiety

Please tick the box

Osteoarthritis

Osteoporosis

Back Pain

Stress

Epilepsy

Do you have any other medical conditions not already identified above? If so, please give details below:

Please list any medications you are currently on:

The personal information you have provided on this form will remain confidential, will not be dislosed to anyone outside of the CUFitter team and will be treated in accordance with the General Data Protection Regulation (GDPR).

Participant Information Consent

I hereby state that I have read, understood and answered honestly all the questions in the questionnaire and that any statements made by me in answering this Pre-Activity Questionnaire are true and accurate.
I realise that my participation in these activities could include the risk of injury and I understand that I am personally responsible for monitoring my own responses during exercise and will inform the fitness specialist immediately or any new or unusual symptoms, changes in my medication and results of any investigations or treatments.
I wish to participate in the CUFitter exercise programme supervised by a fitness specialist. I understand that my participation in the programme is entirely voluntary and that I am free to withdraw at any time.

Please tick the box if you agree to all of the above

Your Signature

Thanks for submitting! Our CUFitterXtra Fitness Specialist will be in touch shortly via email with your online class recommendation.

Want to find out more?

Email: office@cancerunited.org.uk Phone: 01903 779880

Cancer United is a support charity for local people whose

lives have been affected by a cancer diagnosis.

Charity Number: 1155747

Useful Links

Email: office@cancerunited.org.uk

Cancer Prevention

Phone: 01903 779 880

Terms & Conditions