Beautifying Oncology Spa Services
www.beautifyingoncologyspaservices.com
Oncology Esthetics Intake Form
Your responses will enable us to tailor your treatment to meet your unique needs effectively.
Today’s Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Were you referred by someone? If yes by whom
Yes
No
Referred by whom
Emergency Contact Information - Name and Phone #
Have you had a facial or gua sha service before? If yes, when?
Yes
No
If yes when was your last facial treatment?
When were you first diagnosed with cancer?
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Month
-
Day
Year
Date
What type of cancer do you have?
Is your cancer currently active?
Yes
No
Are you in remission?
Yes
No
Where is your cancer located? Ex. bones, breast, etc
Are you currently in active treatment? If yes, what type of treatment? ex. chemo, radiation, etc
Yes
No
If yes, what type of treatment are you currently going through?
When was your last treatment date?
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Month
-
Day
Year
Date
What type of treatments have you undergone, when? Please list dates and types of surgery and/or other treatments.
Current oncology medications that are being taken?
Are you currently experiencing any side effects from your medications? If yes, please describe.
Current non-oncology medications that are being taken?
Have you had any removal or radiation of lymph nodes? If yes please describe when.
Yes
No
If yes, please describe when the lymph nodes were removed or radiated.
How many lymph nodes were removed, where and the date that they were removed?
Currently, do you have any of the following? Please check all that apply
IV or Port
Incisions or open wounds
Drains or dressings
Skin sensitivity, rash or skin conditions
History or risk of blood clots
Lymph node biopsy/disection
Pain or tenderness
Skin grafts
Prosthesis (face, breast, etc.)
Breast lumpectomy or removal
Swelling or tendency to swell
Numbness or reduced sensation
Inflammation
Other
If other , please describe below. Please give details of anything that you have selected above.
Other medical conditions
Allergies
Cardiovascular conditions
Liver or Kidney conditions
Seizures or epilepsy
Respiratory or lung conditions
Diabetes
Injuries
Arthritis or joint problems
Digestive problems
Other
Please give details of anything that you have selected above.
Are your current lab counts normal?
Yes
No
Name of facility where you are/were being treated
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