INTAKE CLIENTS WITH A HISTORY OF CANCERYour 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.)______________________
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____________________________________________________