FitSteps for Life Reassessment Encounter

Qualifying Information - Exercise Specialist enters information




Must have leading zeros




Fact-G Quality of Life

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

Physical Well-Being
Not at all A little bit Some-what Quite a bit Very much
Social/Family Well-Being
Not at all A little bit Some-what Quite a bit Very much
No
Not at all A little bit Some-what Quite a bit Very much
Emotional Well-Being
Not at all A little bit Some-what Quite a bit Very much
Functional Well-Being
Not at all A little bit Some-what Quite a bit Very much

Fact-GP - General Population - V4

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

Physical Well-Being
Not at all A little bit Some-what Quite a bit Very much
Social/Family Well-Being
Not at all A little bit Some-what Quite a bit Very much
No
Not at all A little bit Some-what Quite a bit Very much
Emotional Well-Being
Not at all A little bit Some-what Quite a bit Very much
Functional Well-Being
Not at all A little bit Some-what Quite a bit Very much

FACIT Fatigue Scale

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

Not at all A little bit Some-what Quite a bit Very much


Physical Assessment

Godin Leisure Time Questionnaire

(e.g., Running, hockey, jogging, football, cross country skiing, soccer, basketball, vigorous swimming, vigorous long-distance bicycling)

(e.g., Fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, folk dancing)

(e.g., Yoga, archery, fishing, horseshoes, bowling, golf, easy walking)
Vitals Information






In Inches

In Pounds

In Centimeters






Neurologic Motor Exam


















Physical Assessment





Distance in Miles

Submission Page

This will complete this reassessment, import directly into Salesforce, and create the new encounter within the patient's case. Go to the newly created encounter to complete entering in the reassessment information.

Cancer Foundation For Life | FitSteps for Life | 903-561-0149 | info@fitstepsforlife.org