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Oncology Therapy Form
Oncology Therapy Record
You Yangs Oncology Massage clients are required to complete this form before being treated.
Step
1
of
4
- Contact Details
0%
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Contact Phone
*
Email
*
Occupation
Date of Birth
*
Day
Month
Year
Health Fund
GP Name
*
DR
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Dr
First
Last
GP Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
GP Contact Phone
*
Type of cancer and location:
*
Date of Diagnosis
*
Day
Month
Year
Treatment received
*
Surgery
Chemotherapy
Radiotherapy
Other
Other treatment received
Areas of the body treatment received
*
Are you receiving treatment other than medical as described above?
*
Yes
No
What type of treatment?
Have you completed your treatment?
Yes
No
When did you finish your treatment?
Day
Month
Year
Pressure Related Considerations
Fatigue
Easy bruising (low platelets)
Neutropenia (low white count)
Neuropathy in the hands and/or feet
Lymph node removal in the Axilla, Neck or Groin
Oedema or Lymphodema
Bone Density Loss
Central line in situ
Other
Other Pressure Related Considerations
Skin Related Considerations
Pain or Discomfort
Incisions
Area that feels unusually warm
Skin Problems
Other medical devices
Tumour
Recent history of blood clots
Other
Other Skin Related Considerations
Other Significant Medical History
Positioning Adjustments
I understand that: There is a possibility of slight bruising, depending on the type of therapeutic massage undertaken. There may be one – two days of musculature discomfort after the therapeutic massage treatment as the muscles adjust to their new status. Please drink at least two litres of water per day for optimal health and to also flush the toxins from the body that are released during the therapeutic massage treatment. If the toxins are not released through elimination then headaches and nausea may be present for several days. Confidentiality is respected and at no time is any information received from the client during the therapeutic massage session given to any other person, except with express permission from the client. Therapeutic treatments are given with all due care and practiced with professionalism in a responsible manner by Sally Nicholas, You Yangs Massage.
Can you confirm that all details on this form are correct at this time?
*
Yes
No
Would you like to receive specials or reminders via email?
*
Yes
No
Please tick that you have read our cancellation policy
*
Please call by 10 am on the day prior to your scheduled appointment to notify of any changes or cancellations. To cancel a Monday appointment, please call by 10 am on Friday. Cancellation fee may apply if no prior notification given.
Read Policy
I understand your cancellation policy terms
Signature
*
Any other comment?
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