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meditation, sound and vibration intake form
all fields MUST be filled in.
about you
first name
last name
gender
address
city
state / province
postal / zip code
country
code
home phone number
code
mobile phone number
email
birthday
EMERGENCY CONTACT
code
phone number
relationship
general health information
how would you rate your general health?
*
excellent
good
fair
poor
do you wear hearing aids?
*
yes
no
please list any current medications and the conditions they are treating:
please list any major injuries, accidents or surgeries (including the approx. date):
are you pregnant? if yes, how far along?
do you have any implants? if yes, please list.
do you have any skin conditions? if yes, please list.
do you have any allergies? if yes, please list.
do you have any heart conditions? if yes, please list.
do you have any blood conditions? if yes, please list.
do you have any cerebral conditions? if yes, please list.
do you have cancer? if yes, what is the current state?
do you have any previous experience with sound + vibration?
*
yes, my last sound + vibration treatment was on
no
general
we like to recognize those people/organizations that refer patients to us. please let us know how you found us:
i hereby state that, to the best of my knowledge, my answers to the above questions are correct. i agree to and consent to assessment and treatment. i understand and consent that my medical information may be shared by the various care providers involved in my treatment.
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