Fit to Fight Alumni Class (September 24, 2022)

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Please fill out this form to sign up the Fit to Fight Alumni Class on Saturday, September 24th. A confirmation will be sent via email the week prior to class. Students in the Doctor of Physical Therapy Program at the University of Montana will be reviewing your responses and helping to address any of your concerns and make accommodations that will allow you to make the most of this class. We will be limiting the class to 24 participants.

Email *

What is your name? *

What is your phone number?

When did you participate in Fit to Fight?

Have you participated a past alumni class? If YES, you do not need to fill out the remainder of this form unless you have had a change in your medical status and you would like to update that specific question on the form.

Yes

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Type of Cancer & Year

Medical Information - Please check if any of these apply to you:

Diabetes/hypoglycemia/hyperglycemia

High/Low Blood Pressure

Heart Condition/Pacemaker

Lung Condition

Asthma/Difficulty Breathing

Stroke

Swelling/Joint Pain

Lymphedema

Peripheral Neuropathy

Current Chemo Port in Place

Night Pain

Osteoporosis

Osteoarthritis

Rheumatoid Arthritis

Broken Bones

Surgeries

Vision Impairment

Hearing Impairment

Dizziness/Lightheadedness/Room Spinning

Fainting

Seizures

Heat Sensitivity

Injury to Head/Chest/Organs

Depression

Anxiety

Headaches/Migraines

Other Conditions/Injuries

If relevant, please explain the medical conditions you checked from above:

Any other areas of pain or discomfort not mentioned above?

Ability - Please check if these apply to you:

I can get to and from the floor without assistance.

I require a chair assist for floor transfers.

I can lay flat on my back.

I can lay on my stomach.

I can be on my hands and knees.

I can kneel/be on my knees.

I use an assistive device (cane, trekking poles, etc.) for walking and/or standing balance.

I can bend/twist/lift/exercise without precautions from a healthcare provider.

I have been given exercise precautions from a healthcare provider.

I have not fallen in the past year.

I have fallen 1-3 times in the past year (includes falling into walls or furniture).

I have fallen 4+ times in the past year (includes falling into walls or furniture).

I am concerned about my balance.

I am concerned about my ability to exercise safely.

If relevant, please provide additional explanation of any of the statements you checked from above:

Do you have any concerns regarding this class and/or your physical ability?

Any suggestions for future class ideas?

A copy of your responses will be emailed to the address you provided.

Submit

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