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Oncology Massage Health History & Consent Form
33%
Patient Information
Treatment Recieved
Considerations/Medical History
Patient Information
Personal Information
Name
Date of Birth
Email
Emergency Contact
Name
Phone
Health Professional Information
Name
Phone
Medical History
Type of Cancer and Location
Date of Diagnosis
Date
Oncologist
Next
Treatment Recieved
Surgery/ies
Please Select
Yes
No
Type
Type
Date
Date
Date
Date
Chemotherapy
Please Select
Yes
No
Are you receiving
cyclophosphamide (Cytoxan)
5FU (Fluorouracil)
Intravenous Chemo
Date of Previous
Date
Date of Next
Date
Other Treatment
Please Select
Yes
No
Type
Internal (Brachy therapy)
External (Beam)
What instructions has your radiation oncologist given you?
How is your skin?
Entry port
Entry port
Date of Previous
Date
Date of Next
Date
Radiotherapy
Are you receiving treatment other than the above?
Yes
No
If yes, what type of treatment?
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Considerations/Medical History
Pressure related considerations
Fatigue
Yes
No
Easy bruising
Yes
No
Neutropenia (low white cell count)
Yes
No
Neuropathy (fingers, hands and/or feet)
Yes
No
Lymph node removal (axilla / neck / groin / abdo / popliteal fossa) ( xCa)
Yes
No
Oedema or lymphoedema
Yes
No
Bone density loss
Yes
No
Central line in situ
Yes
No
Date removed
Other
Site Related Considerations
Please select is applicable
Pain or discomfort
Incisions
Area that feels unusually warm
Skin integrity (scarring, healing issues, etc)
Other medical devices
Tumour
Recent history of blood clots
Other
Other Significant Medical History
Acute infection
Yes
No
AIDS
Yes
No
Allergies
Yes
No
Asthma or lung conditions
Yes
No
Blood clots
Yes
No
Diabetes
Yes
No
Diarrhea or other undiagnosed illness
Yes
No
DVT (Deep Vein Thrombosis)
Yes
No
Fibromyalgia
Yes
No
Headaches or migraines
Yes
No
Hearing problems
Yes
No
Heart, circulatory problems
Yes
No
Heat, redness or swelling of the skin
Yes
No
Hernias
Yes
No
High/low blood pressure
Yes
No
Infectious disease/conditions
Yes
No
Motor vehicle accident/trauma
Yes
No
Muscle, bone injury
Yes
No
Muscle or joint pain
Yes
No
Osteoporosis
Yes
No
Phlebitis (leg vein inflammation)
Yes
No
Pregnancy
Yes
No
Seizures
Yes
No
Skin disorders
Yes
No
Stroke
Yes
No
Vision problems or contact lenses
Yes
No
Other condition not listed (please specify)
Leave this field blank
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