Life Now Exercise Recommendation Form

13 11 20 Next Available Apr 24 at 9am

We acknowledge the important role of health professionals in building knowledge of exercise as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment, and greatly appreciate and value your support in linking cancer patients with the Cancer Council WA Life Now Program.

Eligibility criteria

Life Now Exercise is offered to Western Australians who have been diagnosed with cancer in the last two years, are currently undergoing cancer treatment or who have completed cancer treatment in the last two years.

Primary Carers are eligible to register when the patient they support is also enrolled.

We prioritise new participants, giving everyone the opportunity to participate in our Life Now Exercise course.

Exercise Program contraindications include the following health conditions:

Presence of an acute illness, in addition to the initial cancer diagnosis
Any musculoskeletal, cardiovascular or neurological disorder that could place the participant at risk of severe injury or illness resulting from the exercise (excluding conditions/disorders that require exercise as part of their treatment)
Presence of bone metastases*
Presence of myeloma bone disease
Severe anaemia
Neutropenia

Following registration, each participant must gain medical clearance and complete an initial assessment with their assigned accredited exercise physiologist who will develop their individually tailored exercise program (fee applies).

The 12-week (24 class) Exercise course is free of charge to participants, thanks to generous community donations to Cancer Council WA. Participants are asked to commit to attending all or most of the course.

If you have any queries, please call a Life Now Coordinator on 6389 7820 or 6389 7819 or email lifenow@cancerwa.asn.au.

*People with bone metastases may now apply for the Life Now Exercise Joondalup course. Participants will be required to provide the Exercise Physiologist with a radiological scan which identifies the location of the bone metastases( i.e. CT/PET/Bone scan).

Patient Contact Details

Name(Required)

First Last

Email(Required)

Phone(Required)

Cancer Type(Required)

Date(Required)

Select Term(Required)

Term 1 Exercise

Term 3 Exercise

Select Year(Required)

Location(Required)

View Event calendar for current course locations If no courses are currently advertised, we will add this patient’s details to the Life Now mailing list. They will receive Program updates each term

Health Professional Details

Name(Required)

First Last

Email(Required)

Phone(Required)

Organisation(Required)

Role(Required)

Please tick all that apply(Required)

I have advised this patient of the Life Now Exercise format and confirm they are eligible and available to attend the selected 12-week (24 class) Exercise course.

I have advised this patient that there are limited spaces available and this recommendation does not guarantee enrolment in a course.

The patient has consented to being contacted by the Cancer Council WA regarding this request.

We need to collect personal information to process your registration, communicate with you and conduct normal business. By providing your personal information, you agree that your information will be used and disclosed by Cancer Council WA in accordance with our Collection Statement and Privacy Policy.