Oncology Esthetics

INTAKE FORM

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