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Smith Center Three-Day Cancer Retreat Application
This form does not allow you to save your progress, so we recommend completing in one sitting or writing your answers in a word document and pasting them into this form below. For a complete list of questions, see link below.
Application Questions:
https://smithcenter.org/wp-content/uploads/3-Day-June-2023-In-Person-Retreat-Application-Questions.pdf
.
The deadline to submit this application is May 5th, 2023.
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Cell Phone Number
*
Your answer
Home Phone Number
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Occupation or brief work history
Your answer
I am working
Full-time
Part-time
Not working
Retired
Other:
Clear selection
Age
Your answer
Birthdate
Your answer
Ages of children (if any)
Your answer
Are you presently under the care of an oncologist?
Yes
No
Other:
Clear selection
Date of last contact with your oncologist
Your answer
Please provide the name of your Oncologist or primary medical doctor.
Your answer
Please provide the phone numbers for your Oncologist or primary medical doctor.
Your answer
Please provide the city and state where your Oncologist or primary medical doctor is located.
Your answer
Please provide your cancer diagnosis (please be specific)
Your answer
Approximate date of initial diagnosis
Your answer
Dates of recurrence, if any.
Your answer
Do you have any metastases? (If yes, please be specific.)
Your answer
Please list the medical treatments you are CURRENTLY receiving (list type of treatment along with approximate start and end dates:
Your answer
Please list all significant surgical and medical procedures PRIOR TO current therapy (cancer and non-cancer related). List the name of the procedure or therapy along with the dates received.
Your answer
If known, what medical therapies are projected for your future?
Your answer
If you have any in-dwelling tubes, pumps or other devices, please list them here:
Your answer
Please describe any medical or personal care needs that will need attention during the weekend.
Your answer
Are you currently taking medication for pain, depression or other conditions? Please list the medication name, what its prescribed for, the dosage, and the approximate start dates.
Your answer
Are you currently a smoker?
Yes
No
Other:
Clear selection
Please list your height and weight
Your answer
How are you feeling physically?
Your answer
Are you in pain at present? If yes, please describe.
Your answer
Please list the type of complementary/adjunctive therapies you are CURRENTLY using and the approximate dates of usage.
Your answer
Please list the type of complementary/adjunctive therapies you have PREVIOUSLY used and the approximate dates of usage.
Your answer
Please list briefly any major stresses, life changes or losses that have occurred in the past 12 months.
Your answer
Please list the current areas of greatest stress in your life presently (e.g., cancer therapy, relationships, work, finances, etc.)
Your answer
Are you currently seeing a psychiatrist, psychologist or other counselor? If yes, please indicate your start date and any diagnosis received (if applicable):
Your answer
Have you been prescribed any medications related to an psychiatric or psychological issues? Please list the medication name, what its prescribed for, the dosage, and the approximate start dates if you did not include in the medication list in the prior section.
Your answer
What has been the hardest part of your cancer journey?
Your answer
What are the major sources of support or nurture in your life?
Your answer
Do you currently feel that this level of support is sufficient?
Yes
No
Maybe
Other:
Clear selection
How is your morale?
Your answer
How did you learn about the retreat?
Your answer
What are your reasons for wanting to attend the retreat?
Your answer
Do you have any concerns or fears about participating in the retreat? If so, please explain.
Your answer
Can you eat Smith Center’s balanced mostly vegetarian meals which are high fiber & low fat? Note that dairy and eggs are available on the side as an option. No meat, poultry or fish is served at the retreat.
Yes
No
Other:
Clear selection
Do you have any special nutritional needs that our staff should know about?
Your answer
Do you have allergies to foods or medications? If yes, please specify and describe your reactions:
Your answer
Do you have any physical limitations that would make it difficult for you to participate in the program as described in our informational materials (including severe fatigue, climbing small flights of stairs, or walking short distances outside)? If so, please describe.
Your answer
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