Sound Therapy Questionnaire

First Name

Last Name

Occupation

Date of Birth

Address

Phone

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Referral Name

General Health

Rate your level of stress (5 = highest, 1 = lowest) *

What is the main source of stress in your life?

Do you have any sensitivity to sound? *

Yes

Do you have any difficulty lying on your front or back? *

Yes

Please explain which side and the issue?

Please list any accidents or surgeries in the last 2 years

Do you have any metal implants, a pacemaker or body piercings?

List the medications you are currently taking

Sound Therapy

Have you ever had a singing bowl session before? If so, when?

Do you have any allergies?

Goal For Your Sound Therapy Session *

Relaxation

Pain Relief

Stress reduction

Health History

Other (please explain)

Are you pregnant? if so how many weeks?

Are you currently under the care of a doctor or physician? *

Yes

Have you informed your primary care provider that you are receiving ST treatments? *

Yes

Are you currently using any additional techniques to manage stress?

It is my choice to receive Sound Therapy and I understand that the practitioner will be using gentle sounds during the sessions on/around me. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update my practitioner of any changes to my health status. I understand that the practitioner is certified and does not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis, and that is recommended I see a primary health care provider for those services. I understand that I alone am responsible for informing my primary health care provider I am receiving these sessions and inquiring as to whether or not they may adversely affect my current health condition. *

Yes I understand

Privacy Policy: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Sound Therapy Questionnaire

Sound Therapy Questionnaire

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