Emergency Contact Name & Number*
Oncologist Name, Clinic Name & Phone Number*
When were you first diagnosed with cancer?*
What type of cancer do/did you have?*
Where is/was your cancer located?*
Are you currently being treated?*
If yes, when was your last treatment?
What treatments have you undergone and when?*
Please list any medications you are currently taking*
Did your treatment include any removal or radiation of lymph nodes?*
If yes, please describe the location and number of nodes affected
If you received radiation therapy, please describe the location
Do you have any site restrictions due to: incisions, open wounds, drains, dressings, skin sensitivities, rash/skin conditions, IV, port, ostomy, catheter or other device?*
Do you have any pressure restrictions due to (check ALL that apply):*
Do you have any position restrictions due to (check ALL that apply):*
How is your energy level?*
Are/did you experience peripheral neuropathy?*
Any other information the massage therapist should know that is not included above?*
Waiver of Liability and Consent to have Massage*
