Oncology Intake

Required Field

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Contact Info

Mobile Phone

Home Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Diagnosis and Treatment

When were you first diagnosed with cancer?

Characters: 0/255

What type of cancer do you have or have had?

Any known metastases? If so, please specify?

Are you currently in cancer treatment?

Yes

If yes, what type of treatment are you receiving, and to what areas of your body?

If no, when did your treatment finish? What type of treatment did you receive?

General Signs and Symptoms

My oncologist is aware that I am receiving massage?

Yes

Have you had Massage Therapy before?

Yes

If you have had massage therapy before, what did you like and/or dislike?

How would you like massage to support you?

Are there any areas you would like to protect?

If you have positioning needs, please describe.

Do you have any pain or tenderness?

Characters: 0/255

Do you have any swelling or tendency to swell? If so, please specify.

Do you have areas that are warm or red?

Do you have numbness or reduced sensation?

Describe the areas checked above.

Describe the conditions checked above.

Other Conditions

Allergies/Sensitivities (if you use a special lotion, please bring it)

Characters: 0/255

Are you experiencing any skin conditions? If so, please specify.

Cardiovascular Conditions (history of heart condition, high blood pressure, angina, hardening of the arteries, stroke, varicose veins, blood clots)

Liver or Kidney conditions (kidney failure, hepatitis, portal hypertension, etc)

Respiratory or lung conditions (such as emphysema or asthma)

Diabetes (describe type, any medication, whetehr blood sugar is well-controlled, any complications)

Injuries (any back problems, knee problems, tendonitis, disc injuries, neck problems, recent fractures)

Bone or joint problems (such as osteoporosis,. arthritis, or bone metastasis)

Digestive problems (such as colitis, IBS, constipation, diverticulitis, or diarrhea)

Autoimmune (such as lupus, chronic fatigue syndrome, or fibromyalgia)

Hematological conditions (such as anemia, low white blood count, low platelets)

Surgical Procedures

Please list surgical procedures. If lymph nodes were tested as part of the process, please describe the area(s) from which they were removed.

Treatments

Please list all medications you are currently taking, the reason for taking them, and any side effects you are experiencing.

List all chemotherapies - past and present - and include dates.

List other medical treatments, such as radiation or physical therapy, and include treatment dates.

Describe your activity level.

Review & Agree

Massage Client Agreement (Review Required)

You need to review and accept this before submitting

Signature