Vibroacoustic Therapy Intake Survey
Please complete this survey to help us understand your needs and ensure a safe and effective vibroacoustic therapy experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What are your main goals or expectations for vibroacoustic therapy?
*
Please indicate any of the following health conditions you currently have or have had in the past.
*
Heart condition
Epilepsy or seizures
Pregnancy
Hearing impairment
Recent surgery
Acute infections
None of the above
Other (please specify)
Please rate the following symptoms as you experience them currently.
*
Rows
None
Mild
Moderate
Severe
Pain or discomfort
1
2
3
4
Anxiety or stress
5
6
7
8
Sleep disturbances
9
10
11
12
Muscle tension
13
14
15
16
Fatigue
17
18
19
20
Have you previously tried vibroacoustic therapy or similar sound-based therapies?
*
Yes
No
Are you currently taking any medications? If yes, please list them.
Do you have any allergies or sensitivities we should be aware of?
Is there anything else you would like your therapist to know before your session?
Submit Intake Survey
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