Please fill out this form before your first appointment!For those who are receiving an Oncology Massage, please scroll to the Oncology Intake Form.Health History FormHealth History Form Name * Name First First Last Last Date * Date of Birth * Preferred Gender Pronouns * He/himShe/herThey/them Address * Phone * Email * Referred By Emergency Contact Name * Emergency Contact Phone * Have you ever received a professional massage/bodywork before? * Yes No If so, how recently? What kind of pressure do you prefer? * Light Medium Firm Unsure What are your goals/expected outcome for receiving massage/bodywork? * List your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.) * Do these symptoms interfere with your daily activities? (e.g. sleep, exercise, work, childcare)? Yes, No, Explain * List the medications you currently take: * Are you pregnant? * Yes No I don't know Have you had any injuries or surgeries in the past that may influence today's treatment? * Please select any of the following conditions that you currently have (if you are unsure, please ask): Blood clots Infections Congestive Heart Failure Contagious Disease Pitted EdemaPlease indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint pain Numbness or tingling Swelling Muscle or joint stiffness Bruise easily Sensitive to pressure/touch High/low blood pressure Stroke, heart attack Varicose veins Shortness of breath, asthma Cancer Neurological (e.g. MS, Parkinson's, chronic pain) Epilepsy, seizures Headaches, migraines Dizziness, ringing in the ears Digestive conditions (e.g. Crohn's, IBS) Gas, bloating, constipation Arthritis (rheumatoid, osteoarthritis) Osteoporosis,degenerative spine/disk Scoliosis Broken bones Allergies Diabetes Endocrine/thyroid Depression, anxiety Memory loss, confusion, easily overwhelmed If you checked any of these boxes, please explain in the box below if they are past or current symptoms. Additional Comments Consent for treatment: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. * I agree Client Signature * Date * Parent or Guardian Signature (in case of minor) Date If you are human, leave this field blank. SubmitOncology Intake FormOncology Intake Form Name: Address: Phone: Email: Emergency Contact Name: Emergency Contact Phone: Were you referred today? Yes No If yes, who referred you? Today's date: Date of Birth: When were you first diagnosed with Cancer? What type of cancer? Do you have any site restrictions due to: Incisions, open wound, drains or dressings IV, port, stony, catheter Skin sensitivity, rash or skin condition A tumor site Bone/spine metastasis Radiation site History/risk of blood clots or phlebitis Neuropathy Infected area Fracture History OtherAre you being treated now? Yes NoDo you have any pressure restrictions due to: History of lymphedema Fatigue Low platelet count Anticoagulants Steroid meds Fragile/sensitive skin Bone/Spine Metastasis Fragile Veins Fever/Infection Area of pain/burning Recent surgery Other Any sites of pain/tenderness anywhere in your body? If no, what was the date of your last treatment (approx. is fine)? Any sites of numbness or reduced sensation in your body? Any areas of inflammation? What treatments have you undergone (surgeries, chemo, etc)? If possible, please supply details and types of cancer treatments. Skin conditions (rash/itching): Allergies or sensitivities: Current cancer medications not described above: Cardiovascular concerns (such as blood clots, etc): Liver/kidney conditions: Current medications for any other condition: Respiratory or lung conditions: Diabetes: Did your treatment include any removal or radiation of lymph nodes? Yes No Injuries: Arthritis or joint problems: If yes, please describe where: Gastrointestinal problems: Other: Did your treatment include any radiation therapy? Yes No Anything else you think your LMT should know about you? If yes, please describe the areas of your body that were affected. Has cancer/cancer treatment affected any of the following functions in your body? Select all that apply. Heart Kidney Blood counts Energy level Lungs Liver Nervous systemDo you have any position restrictions? Yes No If yes, please describe where: If you are human, leave this field blank. Submit
