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 Personal details
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*

Under 2020-3030-4040-50
Life style

activesedentary
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:*

Cardiovascular Conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)HaemophiliaAny condition already being treated by a GP or another practionerMedical oedemaOsteoporosisArthritisNervouse/Psychotic conditionEpilepsyRecent operationDiabetesAsthmaAny dysfunction of the nervouse system (eg multiple sclerosis, parkinson,s disease,motor neurone diseaseTrapped/pinched nerve(e g sciatica)Inflamed nervecancerCervical spondylitisPostural deformitiesConditions causing muscular spasticity( e.G cerebral palsy)WhiplashSlipped discUndiagnosed painWhen taking prescribed medicationAcute rheumatismOther
Contraindications restricting treatment :*

FeverCutsMenstruation ( abdomen first few days)contagious or infectioious diseaseType option 4BruisesAbrasionsScar tissue( 2 years for major operation and 6 months for small scarVaricose veinsHaematomaHerniaRecent fractures(minimum 3months)Gastric UlcersUndiagnosed lumps and numbsLocalised swellingimflamationPregnancy(abdomen)Harmonal implantsAfter heavy mealSunburnCondition affectiong the neckDiarrhoea and vomitingUnder the influence of recreational drug or alcoholSkin diseasesOther
Client Health information :
Muscular/ skeletal problems :

BackAches/painStiff jointsHeadaches
Digestive problems

ConstipationBloatingliver/gall bladderStomach
Circulation

HeartBlood pressuretired legsFluid retentionVaricose veinsCelluliteKidney problemsCold hands and feete option 8
Nervous system

MigranetensionStressDepression
Immune system

Prone to infectionsSore throatsColdsSinus issues / painChest issues/ pain
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?*

YesNoOther
Do you smoke ?

YesNoOther
Do you drink alcohol? How many units a day?
Do you exercise ?

noneoccasionallyRegularyIrregularOther
Do you suffer or have you suffer from :

DermatitisAcneEczermaPsoriasisAllergiesHay feverAsthmaSkin cancer
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.

NOYes
Written Permission Required (either of which should be attached to the consultation form):
GP/Consultant/Oncologist (PCP) Yes/No *
Informed consent yes/ no*
Disclaimer
Did you read the contraindication ? (the conditions that you can not have massage?*

YesNo
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*

Clear
Date*

MonthDayYear
Date
Therapist Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Client Personal details

Client Health information :

Disclaimer