HOPE LODGE REGISTRATION

American Cancer Society and Maple Tree Cancer Alliance have Partnered to Bring Exercise Oncology to Hope Lodge

We are so excited that you are interested in taking part in the Exercise Oncology services offered by American Cancer Society and Maple Tree Cancer Alliance! Please take a moment to fill out this brief questionnaire with your contact information. We also ask that you fill out the 30 second yes or no questionnaire to ensure that you are a candidate to take part in this program. Once you have submitted this form, a Certified Exercise Oncology Instructor will reach out to you!

Do you have difficulty walking at least a block without using a walker or cane?(Required)
Do you have difficulty doing your daily physical activities in your home (going up or down stairs, cooking, putting on your shirt), or within the community (grocery shopping, doctors appointments)?(Required)
Do you have difficulty moving your arms or legs?(Required)
Have you had any falls or trips since your last visit?(Required)
Do you currently have or feel new or worsening weakness?(Required)
Do you currently have or feel numbness/tingling in your hands or feet?(Required)
Do you currently have or feel reduced endurance?(Required)
Do you currently have or feel heaviness or swelling in your arms, abdomen, or lower legs?(Required)
Do you currently have or feel difficulty with memory, multitasking, or thinking?(Required)
Do you currently have or feel dizziness, blurred vision, or lightheadedness?(Required)

American Cancer Society and Maple Tree Cancer Alliance have Partnered with Hope Lodge in:

Jacksonville, FL

Philadelphia, PA

Oklahoma City, OK

St. Louis, MO

Kansas City, MO

Jackson, MS