Adventure Form

Name: *

Birthday:

Cancerversary:

Email *

Phone:

Physical Address:

Family members with ages and shirt sizes:

Diagnosis:

Diagnosis date:

Oncologist:

Treating Medical Center:

Treatments received:

Date of most recent treatment:

Is the diagnosis chronic?:

Yes
No

Physical limitations/physical concerns:

Please rate the following statements below.
(1=Strongly disagree, 2=Somewhat disagree, 3=Neither agree nor disagree, 4=Somewhat agree, 5=Strongly agree)

1. I experience residual fear (ptsd) from my initial diagnosis and treatments:

2. Fear of recurrence affects my decisions weekly:

3. Fear of recurrence affects my decisions monthly:

4. Fear impacts my life on a daily basis:

5. My cancer experience has negatively affected my children (ages 4-18):

6. My cancer experience has had a negative impact on my relationship with my children:

7. My cancer experience has positively affected my relationship with my children:

8. My cancer experience has had a negative impact on my relationship with my spouse/partner:

9. My cancer experience has positively affected my relationship with my spouse/partner:

10. Cancer impacts my ability to live a happy life:

11. I would describe myself as affected by depression:

12. I have someone in my life who understands what it is like to live with a cancer diagnosis:

Describe how your family envisions their adventure day. (All adventures ideally occur within a 3 hour drive of your home.):

(Optional) If your family has a second adventure idea describe it here:

Any additional relevant information can be included here:

ADVENTURE FORM

Tell us a little about yourself so we can help get your adventure started.