Oncology Massage Therapy Intake Form

Scheduling your appointment

When you have completed this form a Healwell massage therapist will contact you directly to schedule your first session.

Three free massage therapy sessions are available to people affected by cancer who are 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 reciving immunotherapy.

I am currently taking aromatase inhibitors.

I am currently reciving proton therapy.

I have advanced disease.

I would like to receive massage therapy at the following Life with Cancer location:

My preferred days/times are:

Client Information

First name

Last name

Contact name

(If different from the client name.)

Phone number

Email address

Date of birth

Address

City, State and Zip Code

Preferred method of contact

Phone Email Text

What is your occupation?

Is there anything you hope to acheive through massage therapy?

Medical History

When were you diagnosed with cancer?

What type of cancer?

Where is it 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

Add another emergency contact

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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.