Dance4Healing Program Informed Consent

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Did you know? Dancing frequently reduces the risk of dementia by 76%! (1) Creative Arts Therapy improves Quality of Life by 50% and reduces pain by 59% for cancer patients! (2)

Would you like to be a pilot user and help us design the most fun way to help you and other cancer patients recover?

Fill out the Health History form and have your physician sign the hard copy of the Physician Authorization form. Bring completed forms to your first class. All of the information provided on this form is completely confidential.

When: Selected Saturdays 3-4:30pm, please email hello@dance4healing.com or call 1 (562) 281-5188 for dates.

1. New England Journal of Medicine, 2003
2. The JAMA Network, 2013

Name *

Email *

Phone number *

Age *

Home address *

Are you currently in cancer treatment? If not, when did you finish treatment? *

What type of cancer were you diagnosed with? *

When were you diagnosed with cancer? *

What is your occupation? *

What is your ethnicity? *

What is your approximate height and weight? *

What type of treatment did/do you receive? *

Surgery

Chemotherapy

Radiation

Other

Required

What area of the body? *

If chemotherapy or radiation, how many times per month?

Please provide your physician's name, address, and phone number. *

Please check if you currently experience, or have previously experienced, any of the following conditions:

heart attack, coronary angioplasty or cardiac surgery

chest discomfort

lightheadedness or fainting with exercise

shortness of breath with exercise

rapid heart beats or palpitations

heart murmurs, clicks or unusual cardiac findings

high blood pressure

stroke

ankle swelling

numbness, tingling or loss of feeling in hands or feet

peripheral arterial disease, claudication

pulmonary disease including asthma, emphysema and bronchitis

low blood sugar

thyroid condition

high cholesterol

anemia

arthritis (indicate where)

family history of coronary artery disease

Other:

If you currently experience, or have previously experienced, any of the above conditions, please indicate the time period and frequency

Please list all medications that you are currently using:

Indicate any orthopedic problems you might have: *

Do you have permission from your oncologist to exercise? (Your oncologist's consent will be required for you to attend the program.) *

Exercise History

Please check if you have participated in any of the following in the past 6 months:

aerobic dance

swimming

walking

jogging/running

bicycling

tennis or golf

weight training

stretching

Other:

If you have participated in any of the activities above, please indicate how long and with what frequency?

Our program has in-person class 1st and 3rd week on Saturday afternoon, and a virtual class on 2nd and 4th Wednesday evening which you can attend from the comfort of your home. Can you commit to attend these classes? If not, what is your availability? *

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