Name
Date (MM-DD-YYYY)
Address (Include city, state, and zip code)
Home Telephone
Work Telephone
Cell Phone
Email
Date of Birth (MM-DD-YY)
Marital Status Single Married Widowed Separated
Emergency Contact
Relationship
Telephone Number
How did you hear about the DIVA fitness program? (please check one) Doctor Brochure Friend TV Other If you chose Doctor, please list who
I give ThriveWell Cancer Foundation permission to use my photograph or video, artwork, likeness or quoted statements/recordings for publicity. The materials will remain the property of ThriveWell Cancer Foundation and I will not be compensated for such use. Yes, you may use my name, photograph or likeness on materials No, please do not use my name, photograph or likeness on any materials
In order to help ThriveWell Cancer Foundation continue to receive funding for the DIVA Fitness Program, please complete the following questions. This information will not be sold or shared with anyone and is being collected only to provide statistical data. (please check one)
1. Month/Year of breast cancer diagnosis
2. What is your ethnicity? White/Caucasian Black Hispanic Asian Other
4. Do you have health insurance? Yes No
If Yes Medicare Medicaid CareLink Veterans Private Other
If other
5. Do you work full-time? Yes No
6. My total yearly household income is Below $15,000 Between $15,000 and $20,000 Between $20,001 and $30,000 Between $30,001 and $40,000 Between $40,001 and $50,000 Between $50,001 and $60,000 Between $60,001 and $70,000 Over $70,001
7. Total number of people living in your household?
8. Have you served in the military? Yes No
Retired? Yes No
9. Are you or is a member of your family employed by USAA? Yes No
If so, who?
10. If there were a charge for DIVA classes, would you be able to afford to continue attending if classes cost between $12 and $15 each, depending on the class type? Yes No
11. Would you be willing to participate as a volunteer for the DIVA Program? Yes No If Yes, a ThriveWell Foundation staff member will be contacting you with more information.
HEALTH AND WELLNESS SURVEY
Please choose the level of difficulty you have for each activity today.
1. Squatting 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
2. Balancing 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
3. Kneeling 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
4. Walking short distance 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
5. Walking long distance 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
6. Climbing Stairs 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
7. Pulling 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
8. Reaching 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
9. Lifting 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
10. Carrying 1 - Able to do without any difficulty 2 - Able to do with little difficulty 3 - Able to do with moderate difficulty 4 - Able to do with much difficulty 5 - Unable to do 0 - Not applicable
Please choose the response that most accurately describes your current state.
1. How would you currently characterize your health? 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
2. How would you currently characterize your mental health (stress, depression) 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
3. How would you currently characterize your energy level? 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
4. How would you currently characterize your sleep quality? 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
5. How would you currently characterize your mood level? 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
6. How would you currently characterize your mental alertness? 1 - Excellent 2 - Very Good 3 - Good 4 - Fair 5 - Poor
