Oncology Massage Consultation Form

Oncology Massage Consultation Form

In order for me to carry out the safest and most beneficial treatment for you, it is necessary to ask the following questions. Please complete this form prior to attending the studio, at least 48hrs prior to your appointment - that way you can arrive ready to simply relax and enjoy your massage. Once I have received your form, I will create a massage treatment plan that best suits your needs. Please be assured that this can be adapted as required in accordance with any changing needs.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email*
example@example.com
Phone Number*

Area CodePhone Number
Your age range

Under 2020-3030-4040-5050-6060+
Name and contact details (email and telephone) of Oncologist/Consultant/Primary Care Provider.*
Date of last visit to your primary care provider.*
When were you first diagnosed with cancer?
What type of cancer do you have?
Are you currently receiving treatment for your cancer? If yes, what treatment are you receiving and what was the date of your last treatment?
Is your Oncologist/Consultant/Primary Care Provider aware that you will be receiving massage therapy?
If yes, have they made any suggestions or recommendations we need to consider?
Have you had massage therapy before? If yes, was there anything you did 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, hyper/hypotension, heart conditions)Recent operations (cancer and non-cancer related)Postural deformitiesHaemophiliaDiabetesConditions causing muscular spasticity e.g., cerebral palsyAny medical condition already being treated by a GP or other medical practitionerAsthmaWhiplash/slipped disc/trapped or inflamed nerve/sciaticaMedical oedemaNervous system dysfunction e.g., multiple sclerosis, parkinson's disease, MNDArthritisMental health conditions e.g., psychosis, bipolar, schizophreniaAcute rheumatismEpilepsyCervical spondylitis
List any medications, supplements, or herbal remedies you currently take (please be aware that some medications may require prior medical consent)
CONTRAINDICATIONS WHICH MAY RESTRICT MASSAGE TREATMENT:

FeverCuts/bruises/abrasionsContagious or infectious diseasesSkin diseases/disordersHaemetomaHerniaPregnancyMenstruation (within first few days of period at the time of appointment)Diarrhoea and/or vomitingScar tissue (within 2 years for major operations or 6 months for small scars)Recent fractures (minimum 3 months)Varicose veinsGastric ulcersUndiagnosed pain/lumps/bumps/lesionsLocalised swellingHormonal implantsInflammationConditions affecting the neckDigestive problems e.g., constipation, bloating, liver/gall bladder issuesCirculation problems e..g., blood pressure, heart palpitations, cold hands/feet, fluid retentionHeadaches/migrainesImmune system disorders e.g., prone to infection, sinus issues, autoimmune conditionsMetal implantsFibromyalgiaAnxiety/depression/low moodPerimenopause/menopauseSleep problems or sleep disorders
Please list allergies or sensitivities:*
Please list any recent injuries not already highlighted:*
GENERAL HEALTH & LIFESTYLE INFORMATION
How many units of alcohol do you drink per day/week?
Do you smoke? If so, how many cigarettes per day?
Do you exercise? If so, please state which activities and how many times per week.
Approximately how many hours of sleep do you get per night?
Do you suffer/have you suffered from any of the following, acne, dermatitis, psoriasis, eczema, skin cancer? (if yes ,please state which)
ABOUT YOUR MASSAGE TREATMENT & PREFERENCES (please note that whilst all oncology massage incorporates light touch techniques, this information will help me to ensure that you receive the massage that best suits your needs, preferences and comfort)
What benefits would you most like to gain from receiving oncology massage therapy?
What is your stress level right now?

LowAverageSomewhat StressedVery Stressed
What do you consider your skin type?

NormalOilyAcneDryAgingCombinationSensitiveRosaceaOther
DISCLAIMER: For my records, I need to confirm that you clearly understand all of the questions asked and agree with the answers you have shared above. If there is anything you do not understand, please ask me. If you are happy to proceed with massage therapy please read and sign below.

'To the best of my knowledge I confirm that the information I have provided is true and I have not withheld any information concerning my health and wellbeing. I will keep my massage therapist updated on my health should there be any changes to the answers given in this form. I understand there is a possibility that I may experience some minor reactions to massage as my body adjusts to the treatment.

I agree to provide written permission from my oncologist/consultant or other primary care provider in advance of any massage treatment.

I understand that my massage therapist does not diagnose illness, disease or any other physical or mental condition. I understand that the treatment I receive at Sekhem Massage Therapy is not a substitute for medical examination, advice, diagnosis or treatment. Whilst I recognise that all due care and attention will be taken by the therapist, I am aware that my participation in the treatment is voluntary.'
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