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