Medical History Form | Cancer Care & Support

For acupuncture, massage, nutrition, and movement + fitness.

Date(Required)

Section 1

Date of Birth(Required)

Phone(Required)

Email

Referred By

Emergency Phone(Required)

Type of Cancer(Required)

Date of most recent cancer treatment:(Required)

Primary Concern:(Required)

Please describe any conditions that are your primary concerns today.

Section 2

Describe Bleeding Disorder:(Required)

Describe Contagious Illness:(Required)

Describe Heart Disease:(Required)

Where was/is Lymphedema or removed lymph nodes:(Required)

Where was/is pain or tenderness:(Required)

Back Problems experienced:(Required)

Section 3

I understand and agree to the following terms should I decide to use acupuncture, massage therapy, nutrition consult, and/or movement + fitness services.

That I request and consent to the performance of this service(s) within the scope of practice of selected service on me (or on the patient named below, for whom I am legally responsible). That the service(s) I receive is provided for the basic purpose of relaxation, stress reduction, treatment of symptoms related to cancer or cancer treatment, and general wellness. Specific results are not guaranteed. If I experience any pain or discomfort during a session, I will immediately inform the practitioner so that the treatment may be adjusted or discontinued.

That this service(s) should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment.

Because some services are contraindicated (should not be done) under certain medical conditions, I affirm I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so.

That it is up to the discretion of the practitioner to deny or terminate a session based on my apparent physical, emotional, or behavioral condition. That any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and no future appointments will be permitted.

I give the service practitioner permission at his/her discretion to contact my physician with questions regarding my medical history as it relates to Dempsey Center services and to give my physician information regarding the outcome(s) of this and any future sessions. I understand that Dempsey Center complementary therapy practitioners may review my session records but all my records will be kept confidential and will not be released without my written consent.

Dempsey Center Medical History Form

For acupuncture, massage, nutrition, and movement + fitness.

Section 1

Section 2

Section 3

I understand and agree to the following terms should I decide to use acupuncture, massage therapy, nutrition consult, and/or movement + fitness services.

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