Oncology Massage Intake Form

Name ______Today's date ______

Address______

Birth date______Preferred phone______

Email address______

Emergency contact name and phone number ______

Have you had a professional massage before?______When were you diagnosed?______

What type of cancer?______

Where was it located?______

What is the present status of your cancer?______

Are you in treatment now?______Date of last visit?______

Who is your oncologist?______

How often do you see your oncologist?______

Surgery/Procedure: Type ______Date______

Were lymph nodes removed?______Number______Where:______

Reconstruction: Date(s)/Procedure(s): ______

Side Effects: ______

Chemotherapy:

Number of Treatments:______Start Date:______End:______

Side Effects: ______

Radiation:

Number of Treatments: ______Start Date: ______End: ______

Area of Treatment ______Nodes Irradiated in the neck, armpit, or groin? Yes No

Number of Treatments:______Begin Date:______End:______

Area of Treatment ______Nodes Irradiated in the neck, armpit, or groin? Yes No

Number of Treatments:______Begin Date:______End:______

Area of Treatment ______Nodes Irradiated in the neck, armpit, or groin? Yes No

Side Effects: ______

Medical Devices (please circle):

IV Catheter port Breast expander Breast prosthesis Urinary catheter Ostomy feeding tube (PEG) Other______

Has any doctor said anything to you about: Lymphedema? Yes No Bone metastases? Yes No

Side Effects (please circle):

GI Conditions: Nausea Vomiting Low appetite Mouth sores Wt. loss Wt. gain Diarrhea Constipation

Musculoskeletal: Osteoporosis Bone pain Adhesions Incision Headache Touch/pressure sensitivity

Decreased range of motion or function Pain Former injuries Fractures Joint problems Joint replacement

Nervous System: Burn Itch Tingle Prickle Numbness in arms/hands, legs/feet Memory problems

Skin: Skin infection Dry skin Fragile skin Skin irritation Radiation skin reaction Hair loss

Circulatory/Blood: Edema Easy bruising Low platelet Low white count Blood clot Excessively cold/warm

Lymphedema Heart condition High blood pressure Lung condition

General: Fatigue Depression Anxiety Allergies Systemic infection Infectious condition

Other: Current tumor Enlarged nodes/spleen/liver Radioactivity Other:______

Current Medications (Please list the names and side effects):

______

Describe any concerns to your diagnosis and treatment that could affect your massage:

______

Do you have any medical restrictions regarding exercise?

______

Are you being treated by a physician for a condition other than cancer?______

It is my choice to receive massage therapy. I will communicate with my practitioner any time I feel as though my wellbeing is being compromised. I understand that massage therapists do not diagnose illness, disease or any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. If under treatment for cancer, I have informed my massage therapist of any limitations or restrictions. I have stated all medical conditions of which I am aware, including communicable diseases, and I will promptly inform my massage therapist of any issues that arise during the massage.

Signature ______Date ______

2008 Society for Oncology Massage

May be used or adapted with attribution. Adapted by Joybelle Allen 2013