Vibrational Sound Therapy Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email:*

example@example.com

D.O.B*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current methods of relaxation:

What are the main stressors in your life?

Do you have any sensitivity to vibration or sound?

YesNo

Do you have difficulty laying on your front or back?

YesNo

Please list any surgeries or injuries in the last 2 years:

Do you have any metal implants, pacemaker or piercings?

Please list list health history or medications (i.e, heart, blood pressure, anxiety, numbness, tingling, pregnancy, etc.)

Please rate your stress level

Please rate your pain level

Please rate your anxiety level

Any other comments:

I hereby consent to receive on the body sound work. I understand the practitioner will be using gentle vibration and sound during this session on and 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:*