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? _______________________________________________________________________________
1a. Have you had a facial before? YES NO If YES, was there anything that you liked or didn't like? Skin sensitivity?
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 Nance Jack ?___________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Client Signature: ____________________________________ Date: ____________________
Nance Jack Esthetician, Massage Therapist, Eye Lash Specialist/ Owner Spa for the Soul
30622 Santa Margarita Parkway Rancho Santa Margarita, CA 92688 949-690-2369 or 949-766-6362