The Sound Sanctuary
Where you are free to slip into your inner peace!
Name
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First
Last
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
E-mail
*
example@example.com
Birth Year
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How did you hear about me?
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What is our current health goal? What do you hope to get out of this session?
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Please list your main issues and rate them by severity on a scale of 1-10, with 10 being the most severe.
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Please note that we will address as many issues as possible, but it’s often best to deal with fewer at a time.
What do you believe are the causes of these issues?
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Any past accidents? Operations?
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What have you done to help alleviate these issues?
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Emotional checklist - mark all that applies to how you feel
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Anxiety, overwhelmed, stressed
Worried or fearful
Intrusive thoughts, overactive brain
Panic attacks
Unable to relax or loosen up
Stiff or tense muscles
Feeling stressed and burned-out
Obsessive thoughts or behaviors
Perfectionism or being overly controlling
Irritability
Winter blues or seasonal affective disorder
Negativity or depression
Excessive self-criticism
Craving carbs, alcohol or drugs for relaxation and calming
Low self-esteem and poor self-confidence
PMS or menopausal mood swings
Hyperactivity
Anger or rage, agitated easily or irritated
Digestive issues
Fibromyalgia, temporomandibular joint syndrome or other pain sydromes
Difficulty getting to sleep
Insomnia or disturbed sleep
Lack of energy
Lack of focus
Lack of drive or motivation
Attention deficit disorder
Heightened sensitivity to emotional pain
Heightened sensitivity to physical pain
Crying or tearing up easily
Eating to soothe your mood or comfort eating
Is there anything else I should know
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