1386 Yonge Street, Toronto, ON M4T 1Y5. TEL: 416-226-0744

HISTORY OF CANCER

What cancer have you been treated for? ______How long ago? ______
Have you had any bone involvement? If so, where? ______

Do you still have any medical devices? If so, where? ______
Did you have any lymph nodes removed and/or radiated? Yes/No How many? ______
Do you have lymphedema? Yes/No
What residual side effects are you still currently experiencing as a result of your cancer treatment?
______
What supportive medications (supplements) are you currently taking?

(Not including cytotoxic chemotherapy and biological therapy drugs as these are to be listed below under the cancer treatment heading)

Drug name(s) Purpose

Has cancer affected the function of your lungs, liver, kidney, brain or heart? Yes/No
If yes, please list: ______
CURRENTLY UNDERGOING CANCER TREATMENT
What cancer have you been diagnosed with? ______
What cancer treatment(s) are you under currently? ______

ONCOLOGY SURGERY YES/NO
Date of surgery: ______
Tumor site(s): ______
VAD site(s): ______
Other drugs (relating to surgery):
Drug name: Purpose:

Side effects currently experienced: ______


Treatment Provider Notes – Oncology Surgery

Amputation / Anesthesia / Body image issues
Breast reconstruction / Capsular Contracture / Incision site
Infection risk / Itching / Loss of function
Lymphedema / Lymphnode biopsy / Numbness/hypersensitivity
Pain (bone mets) / Pain (surgical site) / Pain (phantom)
Prosthesis (facial) / Prosthetic devices (breast) / Prosthetic devices (implant)
Prosthetic device (expander) / Scarring/adhesions / Skin grafts
Thrombosis / Tumor site (solid)
Wound healing / Tomor site (liquid)


Notes: ______

ANTI-CANCER DRUG THERAPY YES/NO
Cytotoxic Chemotherapy
Start/end date: ______
Chemotherapy Drug(s) - drug names, how many cycles, how far apart
______
Side effects experienced: ______

Biological Therapy
Start/end date: ______

Biological Therapy Drug(s) - drug names, how many cycles, how far apart
______

Side effects experienced: ______

Hormone Therapy
Start/end date: ______

Hormone Therapy Drug(s) - drug names, how many cycles, how far apart
______

Side effects experienced: ______

Esthetician’s Notes – Cytotoxic Chemotherapy:

Allergic reactions / Ascites / Bone fragility
Bone pain / Breathing difficulty / Chemo brain
CINV / Constipation / Diarrhea
Discoloration (skin) / Edema / Extravasation
Hair Loss / Hand-foot syndrome / Herpes (specific)
Immunesuppression / Injection site reactions / Itching
Legs swelling/redness / Low blood counts / Mucosaie (dry)
Nausea, vomiting / Oral mucositis / Peropheral neuropathy
Petechiae rash / Rash variant #1 / Rash variant #2
Rash variant #3 / Rash variant #4 / Rash variant #5
Rash variant #6 / Rash variant #7 / Raynauds/Vasculitis
Smell sensitivity / Sweating / VADs
Waste syndrome(s) / Hair growth / Organ damage

Esthetician’s Notes – Biological Therapy:

Flu-like symptoms / Hair growth / Organ damage

Esthetician’s Notes – Hormone Therapy:

Menopause symptoms

Esthetician’s Notes – Nail Changes

Brittle nails / Separation of nail from nail bed
Discolored nails / Skin infection around nails
Grooves & ridges / Nail infection
Nail loss / Redness/swelling around nail

RADIATION THERAPY YES/NO

External Beam
Start/end date:______
RT site(s): Tumor ______
Lymph nodes ______

Side effects currently experienced: ______

Brachytherapy aka Internal RT
Start/end date:______
RT site(s): Tumor ______
Lymph nodes ______

Side effects currently experienced: ______

Systemic RT
Start/end date:______

Side effects currently experienced: ______


ESTHETICIAN GUIDELINES – EBRT

Fatigue / Erythema
Wet desquamation / Dry desquamation


ESTHETICIAN GUIDELINES –BRACHYTHERAPY

Redness / Bruising
Scar tissue / Pain


ESTHETICIAN GUIDELINES – SYSTEMIC RT

Fatigue / Infection risk

TRANSPLANTATION YES/NO
Start/end date: ______
Chemotherapy Drug(s) - drug names, how many cycles, how far apart
______
Current lab counts
RBC (Red blood cell count) if known ______

Normal range –men / Normal range-women / Anemia / Severe Anemia
41%-53% / 36%-46% / <30% / <21%


WBC (White blood cell count) if known ______

Normal ANC range / Mild neutropenia / Moderate neutropenia / Severe neutropenia
2,500-6,000 cells/mm3 / 1,000-1,500 cells/mm3 / 500-1,000 cells/mm3 / 500 cells/mm3


Platelet Count if known ______

Normal platelet range / Thrombocytopenia / Severe (transfusion may be needed)
150,000-450,000 cells/mm3 / <100,000 cells/mm3 / <10,000 cells/mm3 or <20,000 cells/mm3 with active bleeding


Side effect currently experienced: ______
Esthetician Guidelines - Transplantation

Acute GVHD (red spots & bumps-blisters
Chronic GVHD (rash, discoloration, redness, bumpy, itching, but no hardening-to hardening


Esthetician Guidelines - Nail Changes

Grooves, ridges & brittle nails
Nail loss

PSYCHOLOGICAL
How are you feeling today? ______