Title: Given Name: Surname:

Address:

Suburb: State: ACT New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Postcode:

Email:

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Tel (H): Tel (W): Mobile:

Name:		Relationship:
Phone:		Mobile:
GP Name:		GP Phone:

Do you have Private Health Cover? NO YES

Medicare Number:

Do you have Ambulance Service Membership? NO YES

What type of cancer have you had diagnosed?

Are you currently undertaking treatment for cancer? NO YES

Are there any other significant medical conditions, including physical or mental illness, we need to be aware of?
(eg: heart disease, diabetes, epilepsy...)

Do you have: a pacemaker a colostomy an ileostomy

Do you have any known allergies? NO YES

If yes, please list:

Please list all medications you are currently taking:

Please list any dietary supplements, such as vitamins, minerals etc you are taking:

Please tell us briefly about your motivation for doing this program, any specific issues you would like to address and what you hope to achieve during this time:

How did you find out about this program?

Are you attending the program with a support person? NO YES

If yes, name of support person:

Do you have any hearing or visual impairment? NO YES

Do you require assistance with mobility/seating? NO YES

Is pain likely to be an issue during your sessions? NO YES

Do you feel emotionally supported in your life? YES Sometimes NO

Please specify the support you have:
Family
Friends
Doctor
Counsellor/Psychotherapist
Psychologist/Psychiatrist
Supportgroup
Spiritual
Other

What other support would you need/want in your life?

Have you meditated before? NO YES