Do you have any position restrictions due to:

___incision ___medication ___ostomy ___tumor site ___breathing difficulties ___tender skin
___swelling or risk of swelling (any body area need elevating?)
___medical devices ___discomfort

Please describe ___________________________________________________________

Has cancer or cancer treatment affected any of the following functions in your body?

___Lungs ___Liver ___ Nervous System ___Heart ___Kidney ___Blood counts
___Energy Levels

Please check any that you are currently experiencing and describe _____________________
__________________________________________________________________________

Check “yes/no’ and add comments if you have had or have any of the following:
Yes
No
Comments
Any tendency to swell anywhere on your body?      
Any sites of pain or tenderness anywhere in your body?      
Any sites of numbness or reduced sensation anywhere?      
Any areas of inflammation?      

Other Medical Conditions

Check “yes/no’ and add comments if you have had or have any of the following:
Yes
No
Comments
Skin conditions (rashes, infections, itching)      
Known allergies or sensitivity (if you are using a doctor approved lotion, please bring it)      
Cardiovascular conditions (heart disease, 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      
Diabetes (describe type, medications, blood sugar control, complications)      
Injuries back, neck, knee problems, disc injuries, fractures, etc.)      
Surgeries      
Gastrointestinal Problems      
Arthritis or Joint Problems