Vegananda Wellness

Sound Healing Intake Questionnaire.

CLIENT INTAKE FORM/ HOLISTIC HEALTH ASSESSMENT
The information you fill out on this form will remain CONFIDENTIAL. The
questionnaire is designed to help determine the best treatment plan for you. Please fill
it out as completely as possible.
Name:________________________________________________________ Gender: M F Date:_____________
Home Address:_______________________________________________
City:__________________________________
State:______________ Zip:________________
Email:____________________________________________________
Birth date:__________________ Age:______
Phone:_____________________
Emergency Contact: Name:__________________________________________
Contact phone:___________________
Marital Status: ______single ______married ______divorced ______widowed ______with a
significant other
Are you a caregiver for dependents? Yes No
If yes, how many children?______ How many adults______
Occupation:______________________________________________
How did you hear about Vegananda Wellness?

Have you had sound healing work performed in the past?

If yes, with whom?__________________________ When___________
For what condition?______________________________________________________________
Are you working with any other holistic healing modalities?
If yes, with whom? __________________________ When___________
Please list other treatments
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Please indicate if any of the following pertain to you: (indicating yes does not
make you ineligible for treatment,
however, it may restrict some of your treatment
modalities)
____high blood pressure ____seizures ____pacemaker ____blood-thinning meds
___pregnancy ____Surgically implanted joint/bone replacement or stabilizers

Please list any pharmaceutical medications that you are currently taking.
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Please list any supplements/vitamins that you are currently taking.

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Current Health Concerns

Please list your health concerns in order of priority:
1. ____________________________________________ 4.____________________________________________
2. ____________________________________________ 5.____________________________________________
3. ____________________________________________ 6.____________________________________________
What do you believe is causing your most important health concerns?
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What is your main reason for seeking sound healing?
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How long have you been suffering from this?
__________________________________________________________________
How does it impact your quality of life?
__________________________________________________________________
Have you seen a physician or other health practitioner about this?____________________
When?_________________
What was the diagnosis (if any)?
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Describe any treatment you received and the results:
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Does anything aggravate the condition?
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What improves this condition?
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Habits and Lifestyle

Do you smoke?______ If yes, what?______________ How much per day?________________
Since when? _________
Do you drink alcohol?______ If yes, what?_______________ How much?_________________
How often?_________
Do you exercise regularly?______
If yes, please describe what you do:________________________________________
Do you enjoy exercise? ______
Emotional stress scale Please circle
1 2 3 4 5 6 7 8 9 10
No Stress Moderate Extremely stressed
List the top contributors to stress in your life (job, relationship, time, etc.)
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What do you do when you want to release stress and/or just relax?
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Are you capable of relaxing yourself?
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Is it easy to clear away daily stress?
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Do you consider yourself to be a sensitive/overly emotional person?
__________________________________

What brings you home to yourself? What do you find most centering? (dancing, singing,
painting, hiking, helping other people, listening to a friend, etc)

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Are you aware of mood changes, ups and downs? Are you reactionary? A victim of your
emotions?
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Are you capable of easily expressing your emotions/thoughts etc?
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Are there any emotional states / moods that you experience predominantly? (anger,
depression, etc.)
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What is your favorite climate/weather?
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What is your favorite color?
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Do you prefer a certain genre of music, favorite band/song/instrument?
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If you could do anything you wanted as a career what would it be?
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What are your hobbies/pleasures?

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What are your indulgences?
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Have you ever abstained or quit anything?
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How many hours do you usually sleep per night?____________________

When do you go to bed? _________________

Do you fall asleep easily? _______________________ Stay asleep throughout the night?
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Do you wake feeling refreshed?
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Do you eat/drink before bed?
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Do you dream?
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Do you remember your dreams?
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Do you try to learn from them or write them down?
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Are you in good physical shape for your height/weight? ___________
What are three behaviors you should give up in order to improve your health?
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How often do you have a bowel movement?

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Do they come easily or are you regularly constipated / have diahrrea?
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Are they in general of regular consistency?
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Nutrition
How do you feel about your diet/eating habits?
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Do you struggle with willpower?
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Do you drink coffee?___________ If yes, how much per day?

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Do you drink caffeinated tea?___________ If yes, how much per day?
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Do you drink soda or juice? If yes, for how long?_____________________
Do you eat processed foods? Fast food?
Do you have regular eating habits? Yes No
Do you eat while engaged in other occupations? Yes No
Do you eat more when under stress or feeling depressed? Yes No
Do you experience sudden drops in energy? Yes No If yes, when?
______________________________________
What percent of food do you prepare yourself? What percent is processed? What percent is
restaurant/fast food?
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Do you consider yourself a mindful eater?

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(Are you aware of the ingredients in each one of your food items? Do you chew your
food well? Do you
breathe well while eating? Do you stop eating before bed? Do you
eat to sustain your life or to satisfy
cravings?)
Please describe a typical days diet for you:
Breakfast
Lunch
Dinner
Snacks - how often/times?