Oncology Massage Therapy Intake Form

Scheduling your appointment

When you have completed this form, Healwell will contact you as soon as possible to schedule your first session.

Three free massage therapy sessions are available to people affected by cancer who are INOVA patients in active treatment or are in stages of advanced disease. Active treatment is defined as patients currently undergoing chemotherapy, radiation therapy, proton therapy, aromatase inhibitors and immunotherapy.

Please check all that apply:

I am currently receiving chemotherapy.

I am currently receiving radiation therapy.

I am currently receiving immunotherapy.

I am currently taking aromatase inhibitors.

I am currently receiving proton therapy.

I have advanced disease.

I have no evidence of disease, but side effects remain.

Please share the name of your Inova oncology provider

Client Information

First name

Last name

Contact name

(If different from the client name.)

Phone number

Email address

Date of birth

Address

City

Zip Code

Preferred method of contact

Phone Email Text

What is your occupation?

Is there anything you hope to achieve through massage therapy?

Would you like to receive Healwell's monthly email newsletter?

Yes, please No, thank you

Medical History

When were you diagnosed with cancer?

What type of cancer?

Where is the cancer located?

What treatments have you undergone or are currently undergoing?

To the best of your ability, please try to include dates and types of treatment.

Please list the medications you are taking (other than chemotherapy) and any side effect you experience.

Did your diagnosis and/or treatment include the removal or irradiation of any lymph nodes?

Yes No I'm not sure

If yes, please describe:

Do you notice that cancer/treatment has affected your:

lungs

liver

nervous system

heart

kidneys

blood counts

energy level

Please explain:

Do you have any allergies or sensitivities?

Yes No

If yes, please explain:

Is there anything else you would like your massage therapist to know?

Emergency Contact Information

Please do not list yourself as an emergency contact. In the unlikely event of an emergency it is important that we know who to call.

Add another emergency contact

Thank you for completing this form. A Healwell staff member will contact you as soon as possible.

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Healwell

Healwell is raising the bar for massage therapy's role in the future of how humans will care for humans. Exceptional, meaningfully-integrated massage therapy provided by uncommonly compassionate and skilled massage therapists is a rare thing in today's hospitals and clinics. We're changing that... one therapist, one clinician, one patient at a time.