Oncology Esthetic Care Intake Form

New Client Appointment Checklist

Complete and submit form below

Please arrive at least 15 minutes early for your first appointment.

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These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability. Please contact our Client Advocate if you have any questions or need additional information.



Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.



Your answers to the questions on this form are essential for a safe, effective session. Please take some time to answer in detail, and have this paperwork completed prior to the start of your appointment.

Oncology Facial Contraindications

May NOT be done if you have any of the following:

Presence of infection: edema, pus

Pain: sensitive to touch

Open wounds: wounds that are not healing, susceptible to infection

Rash: vesicles, inflammation, pruritus

Moist desquamation: skin peeling with the presence of infection

Chemo-induced acne: acne lesions produced by systemic chemotherapy

Hypersensitivity: extremely sensitive skin, contact dermatitis

New Client Form

CLIENT INFORMATION:

Name: *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Email: *

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

Have you had a facial before? *

If yes, when was your last facial?

Have you ever had herpes (cold sores)? *

If yes, have you ever been treated with Zovirax or any medication for herpes?

Do you wear contacts? *

Do you smoke? *

Are you on a diet? *

Do you exercise? *

Health & History Questionnaire

Are you currently under the care of a physician for cancer or any other health related issues? *

When were you first diagnosed with cancer?

What type of cancer?

Where was/is it located?

Is this your first type of cancer? *

If not, when was your last diagnosis?

Are you being treated now? *

What was the date of your last treatment?

What treatments have you undergone? Please supply details, with dates and types of cancer treatments.

Current medications not described above:

Please list any allergies:

Did your treatment include any removal or radiation of lymph nodes? *

If yes, please describe where:

Did your treatment include radiation therapy? *

If yes, please describe areas of your body affected:

If you are receiving or had radiation therapy, are you experiencing any burns, discoloration, skin peeling or radiation recall? *

If so, where?

Do you have any site restrictions due to:

incisions, open wounds, drains, or dressings
history or risk of blood clots or phlebitis
IV
Port
Ostomy
Catheter
other device
skin sensitivity, rash, or skin condition
tumor site
radiation site
neuropathy
bone or spine metastasis
fracture history
area of infection
other: (explain below)

Other explanation:

Do you have any pressure restrictions due to:

history of lymphedema
risk of lymphedema
bone or spine metastasis
area of pain or burning
fragile/sensitive skin
steroid medication
fatigue
fragile veins
low platelet count
recent surgery
anticoagulants
infection or fever
other: (explain below)

Other explanation:

Do you have any position restrictions due to:

incision
medication
ostomy
difficulty breathing
tender skin
swelling or risk of swelling (if yes, describe below)
medical devices (if yes, describe below)
discomfort (if yes, describe below)

Details/descriptions:

Does any body area need elevating? *

If yes, please describe:

Has cancer or cancer treatment affected any of the following functions in your body?

lungs
liver
nervous system
heart
kidney
blood counts
energy level

Please describe any you have marked above:

Skin Care History Questionnaire

What concerns you most about your skin today?

If you are here for a facial or waxing, are you using any of the following on your skin? *

Retin-A
Accutane
Renova
Salicylic Acid
Glycolic Acid
Retinols
Lactic Acid
Differens
Benzyl Peroxide
Metro Gel
Botox
Alcohol
Avita
Laser Treatments
Other: (explain below)

Other explanation:

Have you ever had an allergic reaction to any skin product or cosmetic? *

If yes, please list:

What skin care products are you currently using?

Are you currently using any topical or oral medications for your skin conditions or disorders either prescription or over the counter? *

If yes, please describe?

Are you currently experiencing any skin changes due to your medical oncology therapy? *

If yes, please describe?

Do you have any excessive dryness, tightness, dry patches or skin peeling? *

If yes, please describe?

Have you noticed any skin discolorations such as light or dark areas? *

If yes, where and for how long?

Do you have any skin rashes, acne type lesions? *

If yes, where and for how long?

Is your skin sensitive to temperature changes, burning, itching or pain? *

Do you have any wounds that are not healing? *

If yes, please describe:

Are you experiencing any issues with your extremities? (Swelling, peeling, redness, pain, itching) *

Have you received any professional skin treatments recently? Such as, chemical or enzyme peels, or microderm, etc.? *

How often do you cleanse your face? *

Once a day
Twice a day
More often

Do you use an exfoliant? *

If yes, how often?

Do you use a moisturizer? *

If yes, how often?

Do you use an eye cream? *

If yes, how often?

Do you use sunscreen/sunblock? *

Do you sunbathe or participate in outdoor activities? *

Are you allergic to aspirin? *

Are you allergic to iodine or seaweed? *

Do you use Biore or snore strips? *

Do you or have you ever had acne? *

Are you using or have you ever used any medications for acne? *

If yes, please name the medication:

Have you ever had electrolysis or waxing in the past? *

If yes, do you have those services done regularly?

Have you had permanent cosmetics? *

If yes, where?

Have you seen a dermatologist in the past year? *

If yes, list doctor's name and reason for visit:

Have you had any of the following?

Cosmetic Surgery
Botox Injections
Skin Cancer
Hepatitis
Laser Resurfacing
Chemical Peels
Keloid Scarring
Dermatitis

What is it about your skin you would like to change?

General Signs & Symptoms

Check “yes” or “no” and add comments if you have or have had any of the following:

Swelling or tendency to swell anywhere in your body *

Comments

Sites of pain or tenderness anywhere in your Body *

Comments

Sites of numbness or reduced sensation anywhere in your body *

Comments

Other Medical Conditions

Check “yes” or “no” and add comments if you have or have had any of the following:

Skin conditions (rashes, infections, itching) *

Comments

Known allergies or sensitivity (if you use any physician-approved lotion on your skin, please bring it for the massage therapist to use) *

Comments

Cardiovascular conditions (for example: heart conditions, high blood pressure, angina, hardening of the arteries, history of stroke, severe varicose veins, blood clots) *

Comments

Liver or kidney conditions (for example: kidney failure, hepatitis, portal hypertension, etc.) *

Comments

Respiratory or lung conditions *

Comments

Diabetes (describe type, any medication, whether blood sugar is well-controlled, any complications) *

Comments

Injuries (any back problems, knee problems, tendonitis, disc injuries, neck problems, recent fractures) *

Comments

Surgery *

Comments

Important note: It is my choice to receive esthetic care. I understand that the information given above is strictly confidential and will be used for no other purpose than to assist the esthetician in providing suitable service(s) which would take into consideration my specific requirements. I also understand that failure to disclose all my known medical conditions could result in injury and/or illness. I hereby release Well of Life Center for Natural Health, LLC from any claims resulting in such. Any information provided to me by the esthetician is for general purposes only and is not intended for any medical or therapeutic purposes.

Client Signature: *

Clear Signature

Today's Date: *

Please click HERE to read our Agreement and Release of Liability form. Then, sign below. By signing, you are acknowledging that you have read and accept the terms and conditions of the Agreement and Release of Liability.

Client Signature: *

Clear Signature

Phone

Oncology Esthetic Care Intake Form

New Client Appointment Checklist

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability. Please contact our Client Advocate if you have any questions or need additional information.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

Your answers to the questions on this form are essential for a safe, effective session. Please take some time to answer in detail, and have this paperwork completed prior to the start of your appointment.

Oncology Facial Contraindications

New Client Form

CLIENT INFORMATION:

In Case of Emergency, please contact:

Health & History Questionnaire

Skin Care History Questionnaire

General Signs & Symptoms

Other Medical Conditions

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