Oncology Massage Supplement Form 12/5/2024
Required Field
Please fill out this form in addition to the general Therapeutic Lomi Massage Intake Form if you have any history of cancer, whether you're in active treatment, recovery or survivorship. This will help me to provide the most effective and safe session for you.
Personal Info
First Name
Last Name
Contact Info
Email
Current cancer status
in active treatment
waiting to begin treatment
in recovery or survivorship
forgoing treatment or discontinuing treatment
Type of cancer you're currently dealing with and location(s)
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date of current diagnosis
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Name and contact info of oncologist
Treatment(s) received (or waiting to receive) and to which areas of the bodies. Please provide dates.
Have you received or will receive surgery to treat?
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Have you or will you receive chemotherapy to treat?
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Have you received or will receive radiotherapy to treat?
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Are you experiencing fatigue?
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Are you experiencing easy bruising (low platelets)?
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Are you experiencing neutropenia (low white blood cells which make you more prone to infection)?
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Are you experiencing neuropathy (numbness/weakness) of fingers, hands or feet?
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Have you been diagnosed with Oedema or Lymphoedema?
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Do you have bone density loss?
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Do you have a central line or port?
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Do you have any areas that feel unusually warm?
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Do you have any areas of your body that have compromised skin integrity? Rashes, damaged skin?
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Blood clots
Have you ever had a blood clot?
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Have you ever been told you're at risk for blood clots?
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Have you ever had any lymph nodes
tested?
damaged?
removed?
If you answered yes to any of the above questions, please indicate dates, number, etc.
Additional cancer history
Have you had a history of cancer before this current diagnosis?
Yes
No
If you answered yes above, please provide the dates of additional cancer diagnosis with the treatment, outcome and areas of the body affected, including any long-term side effects you're still experiencing.
Positioning
Do you have any positioning restrictions or adjustments needed to be made? If not sure, we will work together to find comfortable positions.
Sessions can include gentle massage over clothes &/or on skin and Reiki energy work,
Would you like to incorporate Reiki & / or energy work into your sessions?
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Most frequently, a combination of over clothing and bare skin massage is shown to be the most therapeutic. Is this option ok with you?
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Would you like to receive your massage over clothing only? (keep in mind, hand massage for example, is considered massage on bare skin)
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Anything else to add?
Please add anything else that could be helpful for me to know in order to provide you a safe and effective session that you have not included here or in the general Therapeutic Lomi Massage Intake Form.
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