Oncology Esthetics


Please complete the form to the best to your ability. Leave blank any questions not applicable to you.

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

    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

    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