Complementary Care Intake Form


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___________________________________________________________


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.