Complementary Care Intake Form

Name:
Doctor:
Date:
Tel.:

Complementary Therapies should be discussed with your physician or nurse.  Please check off any items below so that you can discuss any modifications to these complementary therapies during your chemotherapy.  If you need any additional information on these procedures, please let us know.

Massage Therapy___________________________________________________________

Acupuncture_______________________________________________________

Herbal Remedies___________________________________________________________

Chiropractic Care___________________________________________________________

Spa Therapies that include essential oils, heat treatments, hot tubs, Jacuzzis and body scrubs
___________________________________________________________________

Manicures and Pedicures___________________________________________________

Strenuous exercise_________________________________________________________

Always remember that it is important that the complementary care practitioner is aware of your treatment and that they are trained to take precautions to ensure their treatment care doesn’t cause you undue discomfort or harm during your treatment for cancer.

This form was developed for CISN by Antoinette Muirhead, LMT, CLM Instructor, written permission to use form is requested. www.acaringtouchforcancer.com