top of page





Emergency Contact Name & Number*

Oncologist Name, Clinic Name & Phone Number*

Referred By

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?*

If yes, please describe

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?*

If yes, please describe

Any other information the massage therapist should know that is not included above?*

Waiver of Liability and Consent to have Massage*

Cancellation Policy*

bottom of page