Intake Form — welcome

SET YOUR GPS

・ 7132 Hawaii Kai Drive, Honolulu ・

Driving Directions
•Pass the Hawaii Kai Post Office and look for the Lalea complex on your left

•Turn left into the first entrance then take an immediate right

•Drive forward about 300 feet

•Park in one of the yellow-marked GUEST PARKING stalls on your left

•Walk further and turn left at the fire hydrant to find Unit 122

•Ring the door bell and I'll greet you at the door

Phone
(808) 797-0049

COMPLETE YOUR INTAKE FORM

and submit them at least 12 hours prior to appointment

Acupressure + Reiki Intake Form

Fill this out to the best of your abilities and we can discuss any of these questions more when you arrive

Name

First Name

Last Name

Nickname

Message

Today's Date

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Sex

Gender

Occupation

Enneagram Type (if known)

Favorite Song

Emergency Contact

First Name

Last Name

Emergency Contact

(###)

###

####

How did you hear about us?

If someone referred you, whom may we thank?

Have you ever broken a bone?

If yes, which bone(s)?

Do you experience allergic reactions?

If yes, to which items?

Females, are you possibly pregnant?

If yes, how many weeks will you be at the date of your appointment?

Have you had surgeries in the past?

If yes, what kind?

What conditions would you like me to help you with?

When did it start?

What may have caused it?

Have you been treating it with anything recently?

What makes it better?

What makes it worse?

Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. Hereforward, your care provider, Uakea Egami, will be referred to as “Uakea,” “the provider,” and “ME+U LLC.”

CONSENT TO CARE The nature of the acupressure treatment: The primary treatment the provider uses as an acupressure specialist is meridian alignment, pressure point relief, and aromatherapy. Uakea will use her hands, essential oils, and/or a mechanical instrument upon your body in such a way as to help balance various aspects of your body, such as its joints, muscles, respiratory and nervous system. Based on your feedback, Uakea will choose a specific combination of essential oils that are meant to aid your body’s restoration. Analysis/Examination/Treatment: As part of the analysis, examination, and treatment you may receive the following procedures: • back shu treatment • facial reflexology • exercise instructions • supplement suggestion and instructions • sound therapy. Uakea will ask for access to your back, so she will give you some privacy before your treatment to undress your top. If you do not want any of the above procedures or have questions about any of the above procedures, they should discuss this with the provider as soon as possible. The material risks inherent in acupressure and aromatherapy: As with any healthcare procedure, there are certain complications which may arise during therapy. These complications include but are not limited to: fractures, muscle spasms, skin irritations, tingling and dizziness. Most patients report feeling loopy directly after their treatment and may feel tingling or slight burning on the skin or soreness of the muscles and joints during or following the first few days of treatment as their body becomes accustomed to being in balance. This usually passes in 1-2 days and if it does not the provider should be contacted. Uakea will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform Uakea. The probability of fracture risks occurring are rare occurrences and generally result from some underlying weakness of the bone which Uakea will check for during the taking of your history and during examination. The availability and nature of other treatment options may include: • acupuncture and chiropractic care • physical therapy • and of course, discussion with your primary medical physician.

I have read and understand the above information