<p>¡Vida! Educational Series </p><p>Exercise after Breast cancer: Promoting Healthy, Happy Recovery</p><p>October 11, 2012 Location: ______</p><p>General Information Survey </p><p>1- I am a: (please circle all that apply) Other ______Breast cancer survivor Relative of a breast cancer survivor Caregiver of a breast cancer survivor Health care professional______Lay health worker/ promoter CPG (Community Partner Group member) 2- My residence is in city/town: ______county: ______zip code: ______3- My health insurance is: (please circle all that apply) AHCCCS PCAP Private (please specify) (HMO/ PPO) ______Other______No health insurance Medicare ______4- Age: < 40 40- 49 50- 64 65 + Gender:</p><p>5- Race/ Ethnicity: (please circle all that apply) Native American Caucasian Mixed race Asian/ Pacific Islander African American Hispanic Other _____ 6- How did you hear about this session? </p><p>Before viewing the session: </p><p>My knowledge about this topic is: (circle only one answer) none at all very little somewhat a lot</p><p>Please answer these questions before viewing this session:</p><p>1) What restrictions on exercise are valid after mastectomy? (choose all that apply) a) avoid vigorous aerobic activity </p><p> b) avoid lifting weights or objects over 10 lbs. </p><p> c) start out with low weights and increase incrementally.</p><p> d) exercise only under supervision by a physical therapist.</p><p>2) Identify three or more health benefits of exercise after a cancer diagnosis.</p><p>3) Evidence supports a link between exercise and reduction in cancer recurrence for which types of cancer? (choose all that apply) a) pancreatic cancer </p><p> b) lung cancer </p><p> c) breast cancer </p><p> d) colorectal cancer</p><p>4) For how many cancer patients do you plan to prescribe or recommend physical activity in the next month? </p><p>1 ¡Vida! Educational Series </p><p>______After viewing the session: My knowledge about this topic is: (circle only one answer) none at all very little somewhat a lot</p><p>Please answer these questions after viewing this session:</p><p>1) What restrictions on exercise are valid after mastectomy? (choose all that apply) a) avoid vigorous aerobic activity </p><p> b) avoid lifting weights or objects over 10 lbs. </p><p> c) start out with low weights and increase incrementally.</p><p> d) exercise only under supervision by a physical therapist.</p><p>2) Identify three or more health benefits of exercise after a cancer diagnosis.</p><p>3) Evidence supports a link between exercise and reduction in cancer recurrence for which types of cancer? (choose all that apply) a) pancreatic cancer </p><p> b) lung cancer </p><p> c) breast cancer </p><p> d) colorectal cancer</p><p>4) For how many cancer patients do you plan to prescribe or recommend physical activity in the next month? </p><p>5) As a result of viewing this presentation, will you? (circle all that apply):</p><p>Seek medical care Yes No Share the information with others, if yes, who: ______Yes No Change your practice Yes No Other: ______</p><p>______</p><p>2 ¡Vida! Educational Series </p><p>AFTER VIEWING THE SESSION PLEASE COMPLETE THIS SURVEY</p><p>Sponsored by the University of Arizona College of Medicine at the University of Arizona Medical Center</p><p>ATP – CLINICAL CARE CONFERENCE SERIES GRAND ROUNDS TEACHING EVALUATION</p><p>YOUR NAME (please print): DEGREE / JOB TITLE:</p><p>TODAY’S DATE: 10/11/12 ARIZONA TELEMEDICINE PROGRAM SITE AFFILIATION:</p><p>STATUS: STUDENT  FELLOW  FACULTY  HOUSE OFFICER  OTHER </p><p>PROGRAM TITLE: Exercise Promotes Cancer Recovery SPEAKER: Joy Kiviat, PhD,MSN,RN (OCN), Clinical Instructor, ACSM certified Cancer Exercise Trainer</p><p>STRONGLY NO STRONGL DISAGREE DISAGRE OPINION AGREE Y E AGREE</p><p>This topic is of interest to me 1 2 3 4 5 This topic is relevant to my practice and will ultimately 1 2 3 4 5 improve patient care</p><p>I learned new information 1 2 3 4 5 The teaching techniques were conducive to learning 1 2 3 4 5 The speaker was prepared and informative 1 2 3 4 5 The educational objectives were met 1 2 3 4 5 I would not have been able to attend a lecture on this topic if 1 2 3 4 5 it had not been available via the ATP What other topics would you like to see addressed?</p><p>Did you feel there was a bias toward any particular product or company? Yes__ NO __ If yes, please explain: COMMENTS:</p><p>3 ¡Vida! Educational Series </p><p>THANK YOU</p><p>You may submit the completed forms in any of the following ways:</p><p>Via fax: (520) 626- 5583 Attn: Bettina Hofacre</p><p>Via mail: University of Arizona Cancer Center Attn: Bettina Hofacre 1515 N. Campbell Ave Tucson, AZ 85724 </p><p>Via e-mail to: [email protected]</p><p>If you have any questions please contact:</p><p>Bettina Hofacre at (520) 626-3265</p><p>4</p>