INTAKE – CLIENTS WITH A HISTORY OF CANCER

Your answers to these questions are essential for a safe, effective massage therapy session.  Please take some time to answer in detail.

 Name_____________________________ Phone (day)___________(eve.)______________________
 Address___________________________________________________________________________
 Emergency Contact_______________________________________ Phone______________________
 Have you received massage before? Yes/No   Was there anything you liked or disliked?

 When were you first diagnosed with cancer? _____________What type of cancer?__________________

 Where was/is it located? ______________________________________________________________
 Are you being treated now?  Yes/No   If so, what was the date of your last treatment? ________________
NOTE: If you are currently in treatment, or if your treatment session was less than 12 months ago, please have your physician complete a permission form.  One will be provided. What treatments have you undergone?  Please be detailed with dates and types of cancer treatments.
__________________________________________________________________________________
__________________________________________________________________________________
 Currents medications not listed above____________________________________________________
__________________________________________________________________________________

Did your treatment include removal or radiation  of lymph nodes? (If yes, please describe where)
Did your treatment include radiation therapy? (If yes, please describe areas of your body affected)
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
___tumor site                                 ___radiation site
___bone or spine metastasis    ___neuropathy
___fracture history                       ___infection
___history or risk of blood clots or phlebitis
___other (please describe)
Do you have any pressure restrictions due to:
___history or risk of lymphedema (circle which)
___anticoagulants                        ___low platelet count
___bone or spine metastasis     ___steroid meds
___fragile or sensitive skin         ___fragile veins
___area of pain or burning          ___fatigue
___recent surgery                           ___infection/fever
___other (please describe)