Forms - Therapeutic Sound Healing We

Client Intake Record Form

Therapeutic Sound Healing’s professional code stresses the importance of accurate and up to date client information. All information provided will remain strictly private, confidential and in accordance with Data Protection. Please complete all information below in clear writing:

Sound Healing

"*" indicates required fields

Full name*

(including the name you wish to be addressed as, if different)

Full Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home telephone number

Mobile telephone number

E-mail address

Date of birth

Gender

Are you currently taking any medication?

if yes please give details

Are you currently taking any medication? [ Details ]

Please give details of recent and relevant medical treatment, operations or family history etc

Do you have Epilepsy?

if yes please give details

Do you have Epilepsy? [ Details ]

Are you pregnant or trying to be pregnant?

if yes please give details

Are you pregnant or trying to be pregnant? [ Details ]

Do you have any metal medical implants?

if yes please give details

Do you have any metal medical implants? [ Details ]

Do you have a deep vein thrombosis in the leg or known thrombi?

if yes please give details

Do you have a deep vein thrombosis in the leg or known thrombi? [ Details ]

Do you have any open wounds?

if yes please give details

Do you have any open wounds? [ Details ]

Do you have any acute inflammations and tumours?

if yes please give details

Do you have any acute inflammations and tumours? [ Details ]

Have you recently had any surgery?

if yes please give details

Have you recently had any surgery? [ Details ]

Do you have carotid atherosclerosis?

if yes please give details

Do you have carotid atherosclerosis? [ Details ]

Do you have eczema?

if yes please give details

Do you have eczema? [ Details ]

Do you have any diseased veins?

if yes please give details

Do you have any diseased veins? [ Details ]

Do you have any inflammatory skin disorders?

if yes please give details

Do you have any inflammatory skin disorders? [ Details ]

Do you have any other inflammatory processes generally associated with fever?

if yes please give details

Do you have any other inflammatory processes generally associated with fever? [ Details ]

Do you have a cardiac pacemaker, artificial heart valves, defibrillator or cardiac arrhythmias?

if yes please give details

Do you have a cardiac pacemaker, artificial heart valves, defibrillator or cardiac arrhythmias? [ Details ]

Do you have a shunt?

if yes please give details

Do you have a shunt? [ Details ]

Do you have a stent?

if yes please give details

Do you have a stent? [ Details ]

Do you have a deep brain stimulation device (DBS)?

if yes please give details

Do you have a deep brain stimulation device (DBS)? [ Details ]

Have you had whiplash in the last 3 days ?

if yes please give details

Have you had whiplash in the last 3 days? [ Details ]

Client Record Continued

Are you comfortable with aromatherapy, burning sage, palo santo, incense, essential oils etc.?

How would you describe the level and types of exercise you do?

How would you describe your diet?

How would you describe your sleep patterns?

Do you suffer from stress - and if so are there any triggers and how do you deal with them?

How would you describe your lifestyle including any leisure activities or hobbies etc?

Do you smoke - if so, for how long and how many per day?

Do you drink alcohol - if so how often and how much approx.?

What would you say prompted you to come for this treatment?

What would you like to get out of the treatment?

If pain reduction is indicated, benchmark the current level of pain on a scale of 1 - 10 with 10 being the highest the client has ever experienced.

Are you open to have tuning forks used on the body?

Areas of contact may include meridian points on the hands, feet, calves, head, face, back, shoulders, knees and sternum. You will always be asked before placement of forks again within the session if you are comfortable.

Have you had any other complementary therapies if so which ones?

Have you received any kind of sound therapy in the past? If so when? Please give details.

Please give details.

What is your intention of our sound therapy?

Please include anything you’d like to focus on in our session

Digital Signature

Date*