P.I.P. ONCOLOGY MASSAGE CLINIC Date___/___/_______
Name______________________________ (print) Date of Birth_______________
Address________________________________________________________________________
Phone (day) _____________________ (eve) __________________ Email___________________
1. Have you had Massage Therapy before? Yes No (circle one)
If yes, was there anything you liked or didn't like?
2. Are you familiar with Oncology Massage?
2. What day-to-day activities or exercise (if any) do you currently participate in?
3. When were you first diagnosed with cancer? _____/________Type of cancer?___________
Is the cancer currently active?_______ Where was/is it located?____________________
4. Are you being treated now? Yes No (circle one)
If no, what was the date of your last treatment?_____/_____/_________
NOTE: If you are currently in treatment, between treatments, or if your last treatment session was within one year of the massage session, please have your physician complete the physician consent form.
5. What treatments have you undergone, when? Please list dates and types of surgery and other treatments.
6. What side-effects or long-term effects did (or do) you have from the treatment(s)?
Did your treatment include any removal or radiation of lymph nodes? Any radiation therapy?If yes, please describe where:
Do you have any site restrictions due to:
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9.
_____incisions, open wounds, drains or dressings
_____skin sensitivity, rash or skin condition count
_____IV, port, ostomy, catheter, or other device (circle)
_____a tumor site _____radiation site _____neuropathy _____bone or spine metastasis
_____fracture history _____area of infection _____history/risk of blood clot
_____other (please describe below)
10. Do you have any pressure restrictions due to:
_____history or risk of lymphedema (circle which one)
_____anticoagulants _____low platelet _____bone or spine metastasis _____steroid med
_____fragile/sensitive skin _____fragile veins _____area of pain or burning _____fatigue
_____infection or fever _____other (please describe below)
11. Do you have any position restrictions due to:
_____incision _____medication _____ostomy _____tumor site _____difficulty breathing
_____tender skin _____swelling or risk of swelling (any body area need elevating?) describe
_____medical devices please describe:
_____discomfort please describe:
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(circle any that you are currently experiencing and describe below)
General Signs and Symptoms
Check “yes” and add comments if you Have or have had any of the following:
13. Any swelling or tendency to swell anywhere
in your body? Yes No Comments
14. Any sites of pain or tenderness anywhere in your body? Yes No Comments
15. Any sites of numbness or reduced sensation anywhere
in your body? Yes No Comments
16. Any areas of inflammation? Yes No Comments