Cancer Wellness Program 
Term 2 2024 starts Monday 15th April - Sunday 23rd June. 

All classes are run by Accredited University Practitioners and this pre-intake form is mandatory before starting your free 10-week program with General Wellness Centre (proudly supported by Active & Healthy Gold Coast). 

Please contact us e-mail if you have any concerns or questions. 
admin@generalwellnesscentre.com 

We look forward to having you this term! 
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Email *
I would like to express my interest in the Active & Healthy Cancer Wellness Program Presented by General Wellness Centre, starting April 2024.
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Required
Full Name *
Date of Birth  *
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Phone Number  *
Emergency Contact Name  *
Emergency Contact Phone Number  *
Have you participated in our 10-Week Cancer Wellness Programs before?  *
Let us know a little bit about your journey. Getting to know all our participants before day 1, helps us to create a better and more specific program for you. If you're not yet comfortable enough to share a piece of your story, thats ok too. We will get to know each other soon!
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Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

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Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

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Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

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Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

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If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

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Do you have any other conditions that may require special consideration for you to exercise?

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All exercise has risks, I understand that I must at all times provide all necessary medical information to my care providers to maintain my safety. I understand that I must work within my limits and follow the directions of my care team at all times. I hereby acknowledge my consent to the performance of the proposed care by the accredited Exercise Physiologists & Exercise Scientists. I understand that I can withdraw consent at any time. I understand that I have given my consent voluntarily without duress or inducements being directed at me.

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