Sound Therapy Form | Infinite Evolution

Name

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Date of Birth

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Health History

Do you have metal implants, pins, pacemaker, or body piercings?

Yes
No

If yes, describe what and where.

Any previous surgeries, accidents, or other health diagnosis?

trimester any Layout

Are you sensitive to sounds or vibration, or essential oils?

Yes
No

Have you ever had Energy work or a singing bowl-Sound Therapy-bodywork treatment?

Yes
No

If yes when? What did you like or dislike about it?

Are you, or could you be pregnant?

Yes
No

If yes which trimester are you in? Any complications?

If you are on medications, what are you taking them for?

Do you have any other medical conditions or diagnosis past or present?

Yes
No

Check any that cause you concern:

Root Chakra: (C)

Sacral Chakra: (D)

Solar Plexus Chakra: (E)

Heart Chakra: (F)

Throat Chakra: (G)

Third Eye Chakra: (A)

Crown Chakra: (B)

Reasons for this visit?

Agreement

It is my choice to receive Energy Therapy, Sonic Massage, and/or Sound Therapy and I understand that the practitioner will be using gentle sound and vibration during the sessions on/ around me. I have stated all medical conditions and I will update my practitioner of any changes to my health status. I understand that Sound Therapy Practitioners do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not substitutes for medical examination or diagnosis, and that it is recommended I see a primary health care provider for those services. I understand that I alone am responsible for informing my primary health care provider I am receiving these sessions and inquiring as to whether or not they may adversely affect any current health conditions. With this in mind I agree to have Sound Therapy, massage therapy, aromatherapy, or energy therapy and hold the therapist harmless for any problem that might arise as a result of the session.

Additionally, I accept the cancelation policy requiring 48 hrs advanced notice for any changes to appointments, and understand I will be charged fees if I don’t give at least 24hrs notice.

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