Shine Intake Form

Shine Intake
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General Information

First and last

For FUNDING Purposes

Oncology Medical History

Including any metastasis of your cancer/location

Surgery

Lymph node removal

Chemotherapy

Chemotherapy Administration

Please provide the start dates and end dates of chemotherapy. Please provide the schedule if in active treatment and the name of the drugs being administered.

Radiation

If you have had radiation, please provide the start and end dates. Please provide your schedule if in active treatment.

Blood Work

Please provide current information on blood counts.

Additional Medical History

Allergies

Medications

Pain

Disclaimer

I understand that massage therapy is given here for the purposes of stress reduction, relief from muscular tension or spasm, or for increasing circulation or energy flow. I understand that the massage therapist does not diagnose illness or disease and; therefore, does not prescribe medical treatment, pharmaceuticals, or perform spinal manipulations. Massage therapy is not for sexual gratification. The therapist will maintain appropriate draping at all times. Therapist will not engage in breast massage of female clients. If at any time I am uncomfortable with the massage, I should ask the therapist to stop, change techniques, or end the massage. I have stated all my known medical conditions and acknowledge my responsibility to inform the therapist of any changes. The therapist has the right to refuse providing a massage based on your identified at the time you present for an oncology massage. Your safety is important.

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