Sound Healing New Client Form Name * Including the name you wish to be addressed as (if different) First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone Number * Mobile Phone Number * Email * Name & Address of your Physician/GP * Are you currently taking any medication? * Yes No If yes, please provide details below: Please give details of recent and relevant medical treatment, operations or family history etc * Do you have Epilepsy? * Yes No If yes, please provide details below: Are you pregnant or trying to fall pregnant? * Yes No If yes, please provide details below: Do you have any metal medical implants? * Yes No If yes, please provide details below: Do you have a deep vein thrombosis in the leg or known thrombi? * Yes No If yes, please provide details below: Do you have any open wounds? * Yes No If yes, please provide details below: Do you have any acute inflammations and tumours? * Yes No If yes, please provide details below: Have you recently had any surgery? * Yes No If yes, please provide details below: Do you have carotid atherosclerosis? * Yes No If yes, please provide details below: Do you have eczema? * Yes No If yes, please provide details below: Do you have any diseased veins? * Yes No If yes, please provide details below: Do you have any inflammatory skin disorders? * Yes No If yes, please provide details below: Do you have any other inflammatory processes generally associated with fever? * Yes No If yes, please provide details below: Do you have a cardiac pacemaker, artificial heart valves, defibrillator or cardiac arrhythmias? * Yes No If yes, please provide details below: Do you have a shunt? * Yes No If yes, please provide details below: Do you have a stent? * Yes No If yes, please provide details below: Do you have a deep brain stimulation device (DBS)? * Yes No If yes, please provide details below: Have you had whiplash in the last 3 days? * Yes No If yes, please provide details below: Are there any significant life events that coincided with any medication, illnesses or stress? * E.g: separating from partner, unwell parent How would you describe your diet? * How would you describe the level and types of exercise you do? * 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 a main focus, benchmark your current level of pain on a scale of 1 - 10 with 10 being the highest you have ever experienced Is there anything else that you think might be relevant to the treatment? * Have you had any other complementary therapies if so which and give details? * Have you received any kind of sound therapy in the past? If so when and give details? * I confirm that all information given is accurate and correct at the time of completing this form * Yes Today's Date * MM DD YYYY Thank you.I’m looking forward to supporting you in your upcoming Sound Session. Charlotte x
