In case of guardian or POA arranging the appointment, please note:

Put the name and information for the patient/client who is RECEIVING the massage or energy treatment with the exception of putting the email and phone number of the contact person, guardian or POA (if there is one). All other info should pertain to the patient/client.

If you have legal guardianship, general power of attorney or medical power of attorney, there is a place to fill out your information below that of the personal info section for the patient/client.

This intake form may be a little more extensive than what you've been asked to fill out for prior massage therapy. I appreciate you taking time to fill it out. Everything on here provides valuable information so that I can deliver safe, compassionate, comfortable and effective outcomes for any and all sessions. 

Please do your best to complete your intake at least 24 hours prior to the appointment. 

I am aware that (1) the intent of the massage is therapeutic and not sexual, and (2) I have the right to:

• discontinue the entire massage session, or any part of the session, at any time and for any reason
• request the massage to be given through a drape rather than directly on my body, at any time for any reason
• provide a witness who will be in the room with me while I receive massage

Many times, palliative and hospice massage is very gentle and light work, but not always. It can vary greatly due to the individual. Some of the advanced clinical work I do can affect many medical conditions. Please be forthcoming with your answers so that I may provide an effective and safe session for you.

In the comment box, please indicate time period for each condition:

Decubitus Ulcers (pressure sores, bed sores) are not uncommon when someone is confined to sitting and laying in bed. 

Decubitus ulcers develop in stages, with each stage having distinct symptoms:

Stage I: Discolored skin, often with no open wound
Stage II: Blistering or abrasion
Stage III: Full-thickness skin loss, exposing underlying tissue
Stage IV: Full-thickness skin loss, exposing bone or muscle

Please refer to the above info when answering the following questions.

Certain medications can affect how your body responds to massage. There may be certain forms of treatment that need to be adjusted accordingly. For your safety, please list ALL names of PRESCRIPTION MEDICATIONS AND ANY/ALL NATURAL SUPPLEMENTS AND OVER THE COUNTER REMEDIES regularly taken. 

It's very important for me to know of any recent or past injuries as well as surgeries you may have had. Approx dates, location and name of injury if you know that.

The traditional lomilomi I practice while very clinically based, is also spiritually grounded. As part of this lomilomi practice, I offer a non-religious/non-denominational PULE (blessing) at the beginning of the session for every client in the spirit of aloha.  

I aim to create a comfortable, safe, relaxing space optimum for healing.

I am more than happy to omit this from your session if that is your preferance. THIS IS OPTIONAL.

You will receive the same professional treatment and outcome regardless of your choice.

I can say this silently or out loud. 

Here are a couple of examples:

"Spirit of Peace, Spirit of Harmony, Spririt of love, bless "name of client" from the top of their head to the soles of their feet, throughout every breath and beat of their heart and in all important areas of their life. May "name of client" receive whatever they need today to restore their whole being to one of peace, balance, joy and ease. Aloha and so it is."

"Guide my hands, my head and my heart to make this the very best session possible for "name of client". May they easily access the innate healing that is for their highest good within them to bring about balance, harmony and ease for body mind and spirit. Aloha and so it is." 

I can customize it according to beliefs and preferred vocabulary and add in specific intentions if you wish.