Cancer Massage Medical Authorization Form

Treatment Plan
- Treatment will be a slow, rhythmic mix of massage techniques, adjusted to patient comfort. 
-  Pressure used in oncology massage is staged from 0 - 8.   Refer to Pressure Staging.
-  Listed below are specific restrictions and cautions on site / pressure / patient position.

Appliances
____IV or central line - distal to site only / 0-5
____Port - site / 0 / caution with prone position
____Foley - abdominal / 0 / caution with prone position
____Colostomy/Iliostomy - abdominal / 0 / caution with prone position
____PEG tube - abdominal / 0 / caution with prone position

Hematology
____Thrombocytopenia - below 100 / general / 0-5
____             "                     below 50 / general / 0-3
____             "                     below 20 / general / 0-1
____Leukopenia - general / 0-5 / infection precautions
____Anticoagulant therapy - general/ 0-4
____DVT - lower limbs / 0-1

Oncology
____Tumor - local / 0-1 / Site(s):_____________________________________________________
____Bone metastasis - local / 0-4 (to patient tolerance) / Site(s):_____________________________
____Nodal enlargement - local / 0-4 /  #____ Site(s):______________________________________

        Lymphedema precautions
____Nodal excision, local and distally / 0-4 /   #____Site(s)_________________________________
____Nodal irradiation, local and distally / 0-4 /   #____Site(s)________________________________

Skin
____Incision - local / 0 / for ____________weeks after surgery. Then light work to reorient collagen.
____Skin rash, burn, wheal, disrupted integrity, hypersensitivity, severe itching, lesion - local / 0
____Radiation skin reaction - local / 0-3 / depending on skin condition, use only aloe vera gel.
____Upcoming radiation - Avoid skin products:____________________.  Observe metals precaution.
____Edema - local / 0-4 / elevate.  Treat areas from proximal to distal, within area from distal to proximal.
____Lymphedema - local / 0 / Refer for specialized treatment.

Other
____Constipation - abdomen / 0-6 /  to patient tolerance; clockwise only

Hazard to Massage Therapist
Avoid massage for __________days due to:
_____cyclophosphamide or thiotepa
_____radioactive iodine
_____radioactive implant (site)__________________________
_____other_________________________________________

Other Restrictions, Instructions or Comments
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Physician or RN________________________________________ Date___________________

For a printable version of  this form, goto Reprints.

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by Bruce A. Hopkins