Bodywork With Kahea
Therapeutic Massage • Lomilomi • Cupping • Dolphin Neurostim Therapy 📍 Alana Natural Therapy, Suite 405 Continental Building South King Street, Honolulu, Hawaiʻi 📞 (808) 265-8181 📧 bodyworkwithkahea@gmail.com 📸 Instagram: @bodyworkwithkahea. Kahealani Rivera, LMT
Client Intake & Consent Form
Please complete this form and notify me of any changes to your health history, medications, injuries, surgeries, pregnancy status, or medical conditions prior to each session. Mahalo for being here. ✨
Full Name
*
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Would you like to receive occasional emails from Bodywork with Kahea with wellness updates, special offerings, self-care tips, and promotions?
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Yes, I’d like to join the email list.
No, thanks.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Please select any health conditions or concerns that may be relevant to your session. Do you have any of the following medical conditions?
Allergies
Diabetes
High blood pressure
Heart condition
Pregnancy
Recent surgery or injury
Pacemaker or implanted electrical device
Blood thinner medication
Skin sensitivity or easily bruising
None of the above
Other
Are you currently pregnant?
Yes
No
If yes, please provide your due date and list any pregnancy-related complications, concerns, or restrictions form your healthcare provider:
Are you currently taking any medications or receiving any treatments that may affect your session? If yes, please briefly explain.
Are there any areas of your body you would like the therapist to focus on?
Are there any areas you would like the therapist to avoid?
Do you have any allergies or sensitivities to oils, lotions, or scents?
Is this your first professional massage?
Yes
No
Pressure preference?
Light
Medium
Firm
Unsure/Letʻs discuss
What are your primary goals for today’s session?
Pain Relief
Relaxation/stress reduction
Nervous system support
Recovery from physical tension
Scar support/restriction work
Self-care/wellness
Other
If appropriate for your session goals and health history, are you open to any of the following modalities? (Check all that apply)
Cupping
Hot stones
Dolphin Neurostim (microcurrent point stimulation thearpy)
Scar release therapy
I prefer traditional massage session only
Unsure/open to recommendations
Hot Stones / Thermal Therapy Please complete this section only if you are requesting hot stone or thermal therapy services. Otherwise, leave blank. Hot stones or thermal therapies may not be appropriate for certain medical conditions. Please check any that apply to you:
Diabetes or neuropathy
Sensitivity to heat
Heart or circulatory condition
Pregnancy
Recent injury, inflammation, or surgery
Skin sensitivity or open wounds
None of the above
Cupping Therapy Please complete this section only if you are requesting cupping therapy services. Otherwise, leave blank. Cupping therapy may leave temporary marks/discoloration on the skin and may not be appropriate for certain medical conditions. Please check any that apply to you:
Blood thinner medication
Bleeding or clotting disorder
Easily bruised or fragile skin
Pregnancy
Varicose veins
Recent injury, inflammation, or surgery
Skin irritation, rash, or open wounds
None of the above
Referral/How did you hear about me?
Is there anything else we should know to ensure your comfort and safety?
I understand that massage/bodywork is intended for wellness, stress reduction, and therapeutic support and is not a substitute for medical diagnosis or treatment. I will communicate any discomfort during the session and understand that I may stop the session at any time.
*
I agree
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