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                                                                                    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_______________________________________________

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Peace of Life Massage    211 E. Southlake Blvd., Ste. 114,   Southlake, TX 76092    email: ingrid@peaceoflifemassage.com    214-560-4600





211 E. SOUTHLAKE BLVD., STE. 114
SOUTHLAKE, TX 76092

This website is presented for information only and does NOT offer medical advice. Please consult your doctor regarding medical matters.