Vibrational Sound Therapy Form

Vibrational Sound Therapy Intake Form

on the body sound work and sound therapy
Full Name:
Mobile:
D.O.B

DayMonthYear
Email:
example@example.com
Home Address:
Current methods of relaxation:
What are the main stressors in your life?
Do you have any sensitivity to vibration or sound?
Do you have difficulty laying on your front or back?
Please list any surgeries or injuries in the last 2 years:
Do you have any metal implants, pacemaker or piercings?
Please list health history or medications (i.e, heart, blood pressure, anxiety, numbness, tingling, pregnancy, etc.)
Please rate your stress level 1 - 10 (10 being highest)
Please rate your pain level 1 - 10 (10 being highest)
Please rate your anxiety level 1 - 10 (10 being highest)
Any other comments:
I hereby consent to receive on the body sound work and or sound therapy. I understand the practitioner will be using gentle vibration and sound during this session on and or around me. I have completed this form to the best of my ability. I acknowledge that these sessions are not a substitute for medical examination or diagnosis. I understand that these sessions are for relaxation and a form of self-care.
Signed
Date:

DayMonthYear
Privacy: No information about any client will be discussed with or shared with any third party unless expressly requested by client.
Should be Empty: