Oncology Skin Care Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.CLIENT INFORMATION:Name: *Today's Date: *Home Phone Number:Cell Phone Number: *Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail: *In Case of Emergency, please contact:Emergency Contact Name: *Emergency Contact Phone Number: *Relationship: *Have you had a facial before? *YesNoIf yes, when was your last facial? Have you ever had herpes (cold sores)? *YesNoIf yes, have you ever been treated with Zovirax or any medication for herpes?YesNoDo you wear contacts? *YesNoDo you smoke? *YesNoAre you on a diet? *YesNoDo you exercise? *YesNoHealth & History QuestionnaireAre you currently under the care of a physician for cancer or any other health related issues? *YesNoWhen were you first diagnosed with cancer?What type of cancer?Where was/is it located?Is this your first type of cancer? *YesNoIf not, when was your last diagnosis?Are you being treated now? *YesNoWhat 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? *YesNoIf yes, please describe where: Did your treatment include radiation therapy? *YesNoIf 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? *YesNoIf so, where? Do you have any site restrictions due to: incisions, open wounds, drains, or dressingshistory or risk of blood clots or phlebitisIVPortOstomyCatheterother deviceskin sensitivity, rash, or skin conditiontumor siteradiation siteneuropathybone or spine metastasisfracture historyarea of infectionother: (explain below)Other explanation:Do you have any pressure restrictions due to:history of lymphedemarisk of lymphedemabone or spine metastasisarea of pain or burningfragile/sensitive skinsteroid medicationfatiguefragile veinslow platelet countrecent surgeryanticoagulantsinfection or feverother: (explain below)Other explanation:Do you have any position restrictions due to:incisionmedicationostomydifficulty breathingtender skinswelling 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? *YesNoIf yes, please describe: Has cancer or cancer treatment affected any of the following functions in your body?lungslivernervous systemheartkidneyblood countsenergy levelPlease describe any you have marked above: Skin Care History QuestionnaireWhat 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-AAccutaneRenovaSalicylic AcidGlycolic AcidRetinolsLactic AcidDifferensBenzyl PeroxideMetro GelBotoxAlcoholAvitaLaser TreatmentsOther: (explain below)Other explanation:Have you ever had an allergic reaction to any skin product or cosmetic? *YesNoIf 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? *YesNoIf yes, please describe? Are you currently experiencing any skin changes due to your medical oncology therapy? *YesNoIf yes, please describe? Do you have any excessive dryness, tightness, dry patches or skin peeling? *YesNoIf yes, please describe?Have you noticed any skin discolorations such as light or dark areas? *YesNoIf yes, where and for how long? Do you have any skin rashes, acne type lesions? *YesNoIf yes, where and for how long? Is your skin sensitive to temperature changes, burning, itching or pain? *YesNoDo you have any wounds that are not healing? *YesNoIf yes, please describe: Are you experiencing any issues with your extremities? (Swelling, peeling, redness, pain, itching) *YesNoHave you received any professional skin treatments recently? Such as, chemical or enzyme peels, or microderm, etc.? *YesNoHow often do you cleanse your face? *Once a dayTwice a dayMore oftenDo you use an exfoliant? *YesNoIf yes, how often?Do you use a moisturizer? *YesNoIf yes, how often?Do you use an eye cream? *YesNoIf yes, how often?Do you use sunscreen/sunblock? *YesNoDo you sunbathe or participate in outdoor activities? *YesNoAre you allergic to aspirin? *YesNoAre you allergic to iodine or seaweed? *YesNoDo you use Biore or snore strips? *YesNoDo you or have you ever had acne? *YesNoAre you using or have you ever used any medications for acne? *YesNoIf yes, please name the medication:Have you ever had electrolysis or waxing in the past? *YesNo If yes, do you have those services done regularly? YesNoHave you had permanent cosmetics? *YesNo If yes, where? Have you seen a dermatologist in the past year? *YesNoIf yes, list doctor's name and reason for visit:Have you had any of the following?Cosmetic SurgeryBotox InjectionsSkin CancerHepatitisLaser ResurfacingChemical PeelsKeloid ScarringDermatitisWhat is it about your skin you would like to change? General Signs & SymptomsCheck “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 *YesNoCommentsSites of pain or tenderness anywhere in your Body *YesNoCommentsSites of numbness or reduced sensation anywhere in your body *YesNoCommentsOther Medical ConditionsCheck “yes” or “no” and add comments if you have or have had any of the following:Skin conditions (rashes, infections, itching) *YesNoCommentsKnown allergies or sensitivity (if you use any physician-approved lotion on your skin, please bring it for the massage therapist to use) *YesNoCommentsCardiovascular conditions (for example: heart conditions, high blood pressure, angina, hardening of the arteries, history of stroke, severe varicose veins, blood clots) *YesNoCommentsLiver or kidney conditions (for example: kidney failure, hepatitis, portal hypertension, etc.) *YesNoCommentsRespiratory or lung conditions *YesNoCommentsDiabetes (describe type, any medication, whether blood sugar is well-controlled, any complications) *YesNoCommentsInjuries (any back problems, knee problems, tendonitis, disc injuries, neck problems, recent fractures) *YesNoCommentsSurgery *YesNoCommentsImportant 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.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.NameSubmit Location 203 Farm LaneDoylestown, PA 18901 FollowFollow Spa Hours Mon. 9am – 7pmTues. 10am – 7pmWed. and Thurs. 9am – 7pmFri. 9am – 3pmSat. 8am – 12pm Contact (610) 419-8881 Book An Appointment
