Thank you. Terrie Yardley-Nohr Director of Programming
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1 Welcome to The Healing Arts Center Clinic: Thank you for your interest in our clinic that offers massages to individuals who are currently being treated for cancer. We are pleased to offer this service free of charge and our goal is that we can provide some relief during your treatments. The Healing Arts Center is one of the oldest massage schools in the St. Louis area and has provided quality education to hundreds of massage therapists in the St. Louis and surrounding regions. We have some paperwork that needs to be completed prior to your first appointment. Health Provider Form: please have your current doctor fill out this form. We need to have this form before services can be performed. Client Intake Form: This form is two pages and can take some time to fill out. We are sending this to you prior to your appointment to help alleviate the time in our clinic filling out paperwork. Prior to your massage, you will be meeting with the student therapist and a supervisor in our clinic to talk about your health. Our supervisors are trained in working with cancer patients and will be asking questions to assure that your massage will be a positive and nurturing experience. Together we will determine the best options for your massage. Please feel free to address any questions or concerns to our clinic supervisors. Massage appointments will last for minutes depending on factors that will be determined in the meeting before your massage. We realize that many people may have received or are currently receiving massage. Our therapists will not be performing deep tissue or deep pressure massages. Please feel free to call if you have any questions about the Student Clinic. When you are calling to make your appointment please specify that you are booking an appointment for the Student Cancer Clinic. Please call the number below to book your appointment. Thank you. Terrie Yardley-Nohr Director of Programming
2 Student Clinic Oncologist Form Please have your health care provider fill out the following information prior to your appointment in the student clinic. In an effort to provide a safe and effective massage therapy session, please provide the following information. Patient Name: Type of Cancer: Treating Physician: Physician s Phone: Area of Body: Hospital or Clinic: Hospital Has the pa ent s condi on been treated surgically? Yes No If yes, date. Location of surgery Were any lymph nodes removed? Yes No If yes, from what part of the body? Does the pa ent have lymphedema or is there a risk for lymphedema is any area? Yes No If yes, where? Is the pa ent receiving radia on therapy? Yes No Is the pa ent receiving chemotherapy? Yes No If yes, what side effects does the client have as a result of these treatments? Do any of the treatments or medications that the patient has received effect his or her ability to receive massage therapy? Yes No If yes, what are these considerations? Is the client at risk for blood clots? Yes No Is there any bone metastasis present? Yes No If yes, in what part of the body? Student Clinic The Healing Arts Center
3 Are there any special instructions for the massage therapist? The Healing Arts Center provides free massage therapy services to patients with a cancer diagnosis. The intention of this service is to reduce anxiety, alleviate the sensation of alienation, reduce pain and restore some semblance of quality of life to the patient. The clinic is under the supervision of staff members who are trained in working clients who have been diagnosed with a cancer. Massage sessions are adjusted around the contraindications, needs, symptoms and effects that a client may experience. Your suggestions and approval for massage are an important part of this process for both the patient and our students. If you have any other concerns or suggestions, we welcome your thoughts. Thank you. Physicians Signature: Printed Name: Student Clinic The Healing Arts Center
4 Client Intake Form Name Address: City, State, Zip Emergency Contact Home Phone Cell Phone DOB: Medical Information Have you ever received a massage before? Yes No What is your goal for your massage today? When were you diagnosed with cancer? What type of cancer? Type: Where is it located? Location: Are you currently being treated for cancer? Yes No Please list any treatments you are currently Side Effects: receiving: When was your last treatment? Current Medications and Side Effects: Medications: Side Effects: Has your treatment included the removal of any lymph nodes? If so, please list what area was involved. Has your treatment included any radiation treatments? If so, please list what area was involved. Do you have any site, pressure or position restrictions due to: Incisions, open wounds or drains IV, ports, catheters Radiation Sites Tumor site Skin sensitivities Bone or spine metastasis Neuropathy Areas of infection History or risk of lymphedema Low platelet count Yes Area: Yes Area: No No Swelling History of blood clots Fatigue Medical devices Areas of pain Difficulty breathing Fracture history Anticoagulants Rash or itching Surgery sites
5 Other Medical Conditions Are you currently experiencing any of the following: Swelling Pain or tenderness Numbness of tingling Do you any medical conditions associated with the following: Heart Conditions High Blood Pressure Low Blood Pressure Back/Spine Problems Stroke Varicose Veins Diabetes Asthma Infections/Contagious Disease Allergies Kidneys Liver Reproduction Digestive Joints or Arthritis Location: Explanation: Disclosure I have disclosed all known medical conditions and medications that I am aware of at this time. I understand that I will be receiving a massage from a student or graduate of The Healing Arts Center. I understand that I am responsible for informing the therapists of any changes in my medical conditions. I will also inform the therapist of any issues during the massage such as comfort, pain or pressure. The therapists will not diagnose or medically treat during their session. Client Signature Date Print Name Supervisor Signature Date
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Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
Patient Registration
Acct #: Patient Registration Section I Patient Information Date Last First: M.I. I prefer to be called: Mailing Address: City: State: Zip Home Phone Cell Phone Work Phone Email: Employer: Date of Birth:
4. An RLS symptom journal to help you track your symptoms and discuss them with your clinician.
Information Packet Thank you for your interest in the restiffic restless leg foot wrap. In this packet you will find helpful information for both you and your clinician, including: 1. A custom prescription
Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA
Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA 30328 404 255-8388 www.metroacupuncture.com Patient Information Last Name: First Name: Middle Initial: Street Address: City: State: Zip: Preferred
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home