Peace of Life Massage
Oncology Client Intake Form
Client Name____________________________________________________________Date________________________
M_____ F_____ Date of Birth_______________________________________________________________________
Address_____________________________________________________City________________State/Zip____________
Phone (cell)______________________________Email_______________________________________________________
Type of Cancer and location____________________________________________________________________________
Date of diagnosis________________________ Staging_____________________________________________________
Are you being treated now? No____ Yes______
If yes, how?_________________________________________________________________________________________
If no, when did you finish treatment?____________________________________________________________________
What other types of treatment have you received and to what areas of the body?_________________________________
___________________________________________________________________________________________________
Radiation: No___Yes_____ Dates of treatment:____________________________________________________________
Location of radiation?_________________________________________________________________________________
Chemotherapy: No_____Yes______Dates of treatment:______________________________________________________
Surgery: No____Yes____ What type?____________________________________________________________________
__________________________________________________________________________________________________
Do you have any ports or other internal devices at this time?
No____Yes________Location___________________________________________________________________________
____________________________________________________________________________________________________
Do you know your current blood counts? No__Yes____WBC_________Platelet count______________________________
____________________________________________________________________________________________________
Please list medical drugs you are currently taking. Page 2
Drug Reason
________________________ _______________________________________________________
________________________ _______________________________________________________
________________________ _______________________________________________________
________________________ _______________________________________________________
________________________ _______________________________________________________
________________________ _______________________________________________________
Do you have any current side-effects as a result of treatment?
______________fatigue
______________easy bruising
______________low platelets (thrombocytopenia)
______________low white blood count (neutropenia)
______________neuropathy in the hands or feet
______________lymph node removal in the axilla_____neck______ groin______How many nodes removed?______
______________radiation treatment to axilla _______neck______ groin______
______________edema or lymhedema______location________________________________________
______________bone density loss__________location________________________________________
______________limb central line
______________other medical devices_______location________________________________________
______________pain or discomfort__________location________________________________________
______________incisions_______location___________________________________________________
_______________skin problems ______location______________________________________________
______________area that feels unusually warm ______location__________________________________
_______________recent history of blood clots____when? ___________location_____________________
Page 3
Symptoms related to Chemotherapy or Radiation that you are currently experiencing:
Fatigue ____ Nausea ____ Hair Loss _____ Thirst ____ Diarrhea ____ Constipation ______
Mouth Sores ____ Urination ____ Muscle Aches ____ Loss of appetite ________
Poor Wound Healing _____ Dry Mouth ____ Decrease taste ____ Insomnia ____ Weight Loss ______
Emotional Upset ____ Neuropathy ____ Swelling ____
I understand that the massage I receive is provided for the basic purpose of relaxation through gentle touch and reflexology. If I experience any pain or discomfort during the session, I will immediately inform the therapist. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to my changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Client Signature__________________________________________________ Date _________________
Therapist Signature_______________________________________________
