Cancer/Oncology Massage Intake Form

Health/Lifestyle History and Intake
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth (Include Year)*
Anatomical Gender:
Gender-identity:*
Preferred pronouns:*
Emergency Contact Name:*
Emergency Contact Phone Number:
Emergency Contact Relationship:
What is your occupation?*
How did you hear about us?*

Social Media (Facebook, Instagram, etc)Google searchYelpArlNow/Patch/etcNextdoorOther
Other (name of family/friend, doctor, physician, group, etc. Put N/A if not applicable)*
Would you like to receive emails for the newsletter/promotions/discounts?*

YesNo
Have you ever received bodywork before your cancer diagnosis?*

YesNo
If yes, what types?
Have you received bodywork since your cancer diagnosis?

YesNo
If yes, when and what types?
Do you see a chiropractor?

YesNo
If yes, how often?
Why have you come for massage today?*
Is there anything specific that you hope to achieve through massage?*
When were you diagnosed with cancer and what type?*
Where is/was it located?*
Are you being treated now?*

YesNo
If no, what was the date of your treatment?*
What TREATMENTS have you undergone or are currently undergoing? *
Please supply dates and types of treatments to the best of your ability.
Please list any medications you are currently taking, in addition to any chemotherapy drugs listed above, and any side effects you experience.
Medications: *
Side Effect:*
Did your treatments include any REMOVAL or IRRADIATION of LYMPH NODES?*

YesNo
If yes, please describe.*
To your knowledge, do you have any SITE RESTRICTIONS due to:*

incisions, open wounds, dressingsskin condition, rash or sensitivitymedical devices such as IV or ostomytumor siteradiation site(s)a history of blood clots or phlebitisbone or spinal metastasesneuropathyhistory of fracturesbone fragilityarea of infectionOther (please describe below)None of the above
Other:
To your knowledge, do you have any PRESSURE RESTRICTIONS due to:*

history of risk of lymphedemaanticoagulantslow platelet countbone metastasessteroid medicationfragile/sensitive skinfragile veinsarea(s) of pain or burningfatiguerecent surgeryinfection or feverother (please describe below)none of the above
Other:
Do you have any POSITION RESTRICTIONS due to:*

incisionmedicationostomytumor sitedifficulty breathingtender skinswelling or risk of swelling (any area of the body require elevating? Describe below)medical devicesdiscomfortnone of the above
Please describe any area of the body that may require elevation:
Has cancer or cancer treatment affected any of the following functions in your body?*

lungslivernervous systemheartkidneyblood countsenergy levelnone of the above
If yes, please describe:
General Signs and Symptoms

Check "Yes" & add further comments if you have had any of the following signs/symptoms*

	Yes	No	Comments
Swelling or tendency to swell anywhere in your body
Sites of pain/tenderness
Sites of numbness/diminished sensation
Inflammation

Specific Medical Conditions

Check "Yes" & add further comments if you have had any of the following signs/symptoms*

	Yes	No	Comments
SKIN CONDITIONS (rashes, infections, allergies, itching)
Known ALLERGIES/SENSITIVITIES (Do you use any non-allergenic or physician-approved lotion?)
CARDIOVASCULAR CONDITIONS (e.g. heart condition, angina, high blood pressure, arteriosclerosis, phlebitis, thrombosis, etc)
LIVER or KIDNEY conditions
RESPIRATORY or LUNG CONDITIONS
DIABETES
ARTHRITIS
INJURIES (e.g. disc problems, tendonitis, knee problems, fractures, etc)
Surgery
Any conditions NOT MENTIONED

How would you rate your DIET?*

Very HealthySomewhat HealthyNot Very HealthyNeeds Improvement
How much uninterrupted SLEEP do you get each day, on average?

None1-3 Hours4-5 Hours6-7 Hours8+ Hours
If you are having trouble sleeping, what is the primary reason?*

AnxietyPainOutside interruption (family, noise, etc)Other (Please explain below)None of the above/Not applicable
Other reasons for trouble sleeping:
On average, how much WATER do you drink each day? (as a reference, a soft drink-can contains 12 oz.)*

Less than one 8oz. GlassMore than five 8oz. GlassesEight or more 8oz. Glasses
Are you ABLE TO RELAX?*

YesNo
What do you usually do to relax?
Is there ANYTHING ELSE that you think I should know?
Please indicate any areas of discomfort or pain. Rate your discomfort using a scale of 1-10. 1= Very mild; 10=Extreme, intrusive pain.*

1

2

3

4

5

6

7

8

9

10

1 is Most Mild, 10 is Worst
Please indicate corresponding areas of body for pain and note anything you feel requires explanation:

CLIENT AGREEMENT
I,blanks*, give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.

I also understand:
1. That massage therapy and/or acupuncture:
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists:
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Welcome! Thank you for choosing The Teal Center. Please READ and INITIAL each of the following:
POLICIES
blanks* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
blanks* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.
blanks*If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
blanks*In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
blanks* Tips are appreciated but never expected. If you wish to leave a gratuity, we ask that you do so in cash or by check made directly to the therapist. Gratuity is also made possible via the Venmo app for some therapists.
blanks* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
blanks* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Health/Lifestyle History and Intake

General Signs and Symptoms

Specific Medical Conditions

CLIENT AGREEMENT

Welcome! Thank you for choosing The Teal Center. Please READ and INITIAL each of the following:

POLICIES