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
