Intake Form

First Name*

Last Name*

Email*

What type of cancer(s) have you been diagnosed with?

How would you best describe your stage of cancer/treatment:
Currently having treatmentRecently completed treatmentMetastaticIn RemissionLong-term survivor

Incision: Date

Incision Site(s):

Radiation Therapy: Date of Completion

Radiation Site(s):

Cryotherapy: Date

Cryotherapy Site(s):
*For cancerous or pre-cancerous epidermal lesions

Chemotherapy: Date of last Infusion

Please list areas where lymph nodes were removed or radiated.

How many lymph nodes were affected ?
01-56-10More than 10I'm not sure

Please indicate if you have any of the following:
PICC LinePort-O-CathOmmaya ReservoirOstomy/Stoma

Please check all skin concerns you are currently experiencing:
Radiation BurnsSurgical ScarsItchingRashPapules or PustulesDry SkinDry MucosaePoor Wound HealingBruisingPatechiaeHyper/HypopigmentationWet DesquamationFungusVirusHypersensitivityHand Foot SydromeOther [group group-skinconcerns][/group]

Please indicate all nail/cuticle concerns you are currently experiencing:
FungusInfectionInflammationIngrown ToenailsLifting NailsDry/Brittle/Peeling NailsDiscolorationUnusual Nail Ridges

Has cancer or cancer treatment affected any of the following functions?:
LungsKidneysLiverHeartBlood CountsNervous SystemDigestive System

Please indicate any other side effects you are currently experiencing:
NauseaFatigueChillsDizzinessShortness of BreathPeripheral NeuropathyImmunosupressionAnxietyDepressionEdema/LymphoedemaPainBone FragilityAlopeciaPhysical ImpairmentsOther [group group-sideeffects] [/group]

Please list all medications you are currently taking and why:

Please list all allergies

Please add any other concerns or questions you have

What spa services are you most interested in?

I understand that it is in my best interest to consult my doctor before receiving spa treatments.

I understand that because of my medical history, oncologic therapy(ies), and medications, that some skin conditions may require ongoing maintenance to achieve desired results.

I acknowledged that all the information provided by me is true and correct to the best of my knowledge.

Date