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
