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
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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.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Information - Name and Phone #
Were you referred to us? If so, please share the name of the person or organization that referred you.
When did you last receive a facial treatment? Did you experience any complications?
What type of cancer have you been diagnosed with, and when did you receive your diagnosis?
What is the current status of your cancer?
Active
In Remision
N/A (Not Applicable)
Please specify the location of your cancer (e.g., breast, lungs, etc.):
What type of treatments have you undergone, when? Please list dates and types of surgery and/or other treatments.
When was your last treatment date?
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Month
-
Day
Year
Date
What oncology medications are you currently taking? Are you experiencing any side effects from your medications? If yes, please specify
Current non-oncology medications that are being taken?
Have you had any lymph nodes removed or radiated? If so, please specify how many, their locations, and the dates of the procedures.
Currently, do you have any of the following medical conditions ? 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.
Do you have any other medical conditions? Please check all that apply.
Allergies
Cardiovascular conditions
Liver or Kidney conditions
Seizures or epilepsy
Respiratory or lung conditions
Diabetes
Injuries
Arthritis or joint problems
Digestive problems
Other
If other, please specify.
Are your current lab counts normal?
Yes
No
Name of facility where you are/were being treated
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Signature
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