Oncology Services
If you have been treated for cancer in the past 12 months or are currently in treatment for cancer, please fill out this form. Your answers to the questions on this form are essential for a safe, effective massage therapy session. Please take some time to answer in detail.
Full Name: _____________________________________________ DOB: ____________________________ Address: __________________________________________________________________________________ City: ________________________________________________ State: _________ Zip: __________________ Phone #: ____________________________Email: ________________________________________________ Occupation: ____________________________________________
Emergency Contact: _____________________________________ Phone #: ___________________________ Relationship: ________________________________________ Physician: _____________________________________________ Phone #: ____________________________
1. Have you had massage therapy before?: !YES !NO
If YES, was there anything that you liked or
didn’t like? _______________________________________________________________________________
2. When were you first diagnosed with cancer? ______________ What type of cancer? ___________________
3. Where was/is it located? ___________________________________________________________________
4. Are you being treated now?!YES !NO If NO, what was the date of your last treatment? ___________
NOTE: if you are currently in treatment, or if your last treatment session was less than 12 months ago, please have your physician complete the accompanying permission form.
5. What treatments have you undergone? Please supply detail, with dates and types of cancer treatments. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
6. Medication
For what condition?
Effective?
Side-effects?
7. Did your treatment include any removal or radiation of lymph notes? !YES !NO
(If yes, please describe where) ___________________________________________________
8. Did your treatment include radiation therapy?
!YES !NO (If yes, please describe areas of your body affected)
__________________________________________________
9. Do you have any site restrictions due to: ___ incisions, open wounds, drains or dressings ___ skin sensitivity, rash or skin condition ___ IV, port, ostomy, catheter, or other device (circle)
___ a tumor site ___ bone or spine metastisis ___ fracture history ___ history or risk of blood clots or phlebitis ___ Other (please describe) _____________________
___ radiation site ___ neuropathy ___ area of infection
10. Do you have any pressure restrictions due to: ___ history or risk of lymphedema (circle which)
___ anticoagulants ___ bone or spine metastisis ___ fragile/sensitive skin ___ area of pain or burning ___ recent surgery ___ Other (please describe) ___________________ __________________________________________
___ low platelet count ___ steroid medication ___ fragile veins ___ fatigue
___ infection or fever
11. Do you have any position restrictions due to: ___ incision ___ medication ___ ostomy ___ tumor site ___ difficulty breathing ___ tender skin ___ swelling or risk of swelling (any body area need elevating?) (please describe)________________________ ___ medical devices (please describe): __________________________________________________________ ___ discomfort (please describe): ______________________________________________________________ 12. Has cancer or cancer treatment affected any of the following functions in your body? ___ Lungs ___ Liver ___ Nervous system ___ Heart ___ Kidney ___ Blood counts ___ Energy level (circle any that you are currently experiencing and describe) _____________________________________
General signs and symptoms
Check “yes” and add comments if you have OR have had any of the following:
Yes
No
Comments
13. Any swelling or tendency to swell anywhere in your body?
14. Any sites of pain or tenderness anywhere in your body
15. Any sites of numbness or reduced sensation anywhere in your body?
16. Any areas of inflammation?
Other Medical Conditions
Check “yes” and add comments if you have OR have had any of the following:
Yes
No
Comments
17. Skin conditions (rashes, infections, itching)
18. Known Allergies or Sensitivity (if you use any physician-approved lotion on your skin, please bring it for the massage therapist to use)
19. Cardiovascular conditions (for example: heart condition, high blood pressure, angina, hardening of the
arteries, history of stroke, severe varicose veins, blood clots)
20. Liver or Kidney conditions (for example: kidney failure, hepatitis, portal hypertension, etc.)
21. Respiratory or Lung conditions
22. Diabetes (describe type, any medication, whether blood sugar is well-controlled, any complications)
23. Injuries (any back problems, knee problems, tendonitis, disc injuries, neck problems, recent fractures)
24. Arthritis or Joint problems
25. Gastrointestinal problems
26. Surgery
Is there anything else you would like to tell me?___________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Client Signature: ____________________________________ Date: ____________________
Thank You , Nance Jack