Oncology-massage-consultation-form (Cancer massage)

Oncology Massage Consultation Form and Treatment Plan

In order for me to carry out the safest and most beneficial treatment for you, it is necessary to ask the following questions.

Client name

Occupation

Number with prefix +

Email address

example@example.com

Client Personal Information and Primary Care Provider:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your age range

Life style

Last visit to your Primary Care Provider

When were you first diagnosed with cancer?

What type of cancer do you have?

Are you currently being treated for cancer? Yes/no. what was the date of your last treatment? and what treatment was this?

Is your PCP aware you will be receiving massage therapy ? Yes/ No if yes , have they made any suggestions or recommendations?

Have you had massage therapy before? Yes/No and if yes was there anything you liked or didn't like?

Contraindications Requiring Medical Permission * In circumstances where medical permission cannot be obtained, clients must give their informed consent in writing prior to treatment:

Contraindications restricting treatment :

Muscular/ skeletal problems :

Digestive problems

Circulation

Nervous system

Immune system

Are you taking medication? yes/ no if yes what is it ?

How many ofthese drinks per day ? Tea , coffee ,water, juice,soft drinks , others

Do ou have any allergies?

Other

Do you smoke ?

Other

Do you drink alcohol? How many units a day?

Do you exercise ?

Do you suffer or have you suffer from :

To be completed by the therapist:

Treatment for Cancer (chemotherapy, radiation, or surgery? Any areas to be avoided?)

Contraindications Requiring Medical Permission (If SO, which and what you will do?)

Contraindications Restricting Treatment (If SO, which and what you will do?)

Client Lifestyle Information (Is there anything that is important and may affect treatment plan ?)

Treatment Plan (What treatment will you carry out? How long will the treatment last? Are any adjustments or modifications needed?)

Client Feedback

Home care provided? General aftercare rule: after massage therapy ensure that you do not stand up too quickly. You must also give your blood pressure a chance to return to normal after being relaxed for so long. We’d also advise you to drink plenty of water following your massage to rehydrate your body.

Written Permission Required (either of which should be attached to the consultation form):

GP/Consultant/Oncologist (PCP) Yes/No

Informed consent yes/ no

Did you read the contraindication ? (the conditions that you can not have massage?

For my records, I need to confirm that you clearly understand all of the questions asked and agree with what has been written. If there is anything you do not understand, please

To the best of my knowledge, the information I have given is true, and I have not withheld any information concerning my health. I will keep (name of therapist) updated on my health should there be any changes to answers given. I understand there is a possibility I may experience some minor reactions as my body adjusts to the treatment.

I understand that the therapist does not diagnose illness, disease or any other physical or

mental condition. I understand that this treatment is not a substitute for medical

examination, diagnosis, or treatment. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary.

Client Signature

Date

Therapist Signature

Date

Client Personal details

Client Health information :

Disclaimer