physio questionnaire

Please fill in the questionnaire below to help us better understand our Pink Pilates clients and evaluate our service:

(required form fields are bold)

Date of First Assessment:

Client Code:

Surgeon's Name:

Region:

Physio Clinic Name:

Question 1:
Age of the client at their last birthday?
Less than 20 years old
21 - 39 years old
40 - 54 years old
55 - 65 years old
65 years and over

Question 2:
Ethnicity of the client?
European/New Zealander
Australian
Maori
Pacific Islander
Asian
Aboriginal
Indian
Other

Question 3:
Working status of the client?
Not working
Housewife
Student
Working full-time
Working part-time
Retired
Unemployed

Question 4:
Type of Cancer?
Breast Cancer
Bowel Cancer
Secondary Breast Cancer
Lung Cancer
Gynaecological Cancer
Lymphoma
Other

Question 5:
What phase of recovery is the client in?
Phase 1 = post op
Phase 2 = recovery
Phase 3 = fitness

Question 6: (select all that apply)
What type of cancer treatment has the client had, or needs to have?
Hormone therapy
Chemotherapy
Radiation therapy

Question 7: (select all that apply)
What type of reconstruction surgery has the client had?
None
TRAM FLAP reconstruction
LAT reconstruction
IMPLANT

Question 8: (select all that apply)
Has the client experienced any post op complications?
No
Seroma
Lymphoedema
Frozen shoulder
Poor/delayed wound healing
Surgical complications

Question 9: (select all that apply)
Please indicate any goals the client has from the Pink Pilates Programme.
Improve flexibility
Improve strength
Improve posture
Improve fitness level
Improve energy levels/manage fatigue
Improve feelings of well being
Reduce pain
Weight maintenance
Other

Question 10:
Please indicate which exercise category your client fits in.
Non - Exerciser
Exerciser before diagnosis but not currently exercising
Keen Exerciser (currently exercising)

Question 11:
How did the client hear about Pink Pilates?
Breast Nurse referral
Doctor or Surgeon referral
Cancer support referral
Website
Friend or family
Brochure
Advertisement
Other

Question 12:
Please indicate which category your client fits in.
Paying privately
Medical insurance
Funding through the Pink Pilates Trust
Other funding source

Question 13:
Did the client have to go on a waiting list to receive funding before they could start the programme?
Yes
No

Question 14:
Did the client start the programme without funding but is on a waiting list for future funding?
Yes
No

Security Number:

Enter Security Number: