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Client Information Questionnaire

Please fill out as much as you can so that I have the information needed to give you the treatment and healing that you need. If you have filled out this form within the last 6 weeks and nothing has changed, you do not need to fill it out again.

Birthday
Do you have any sensitivity to vibration or sound?
Yes
No
Do any of the below apply to you?
Are you taking any medications?
YES
NO
Do you have any metal implants, pacemaker or piercings?
Please rate your stress level:
1 (Very Low)
2
3
4
5 (Very High)
Please rate your pain level:
1 (Very Low)
2
3
4
5 (Very High)
Please rate your anxiety level:
1 (Very Low)
2
3
4
5 (Very High)

I voluntarily participate in Talena Cuthbert’s sound healing session, understanding its use of sound for therapeutic purposes, and acknowledging its risks. I acknowledge that these sessions are not a substitute for medical examination or diagnosis. I understand that these sessions are for relaxation and a form of self-care. I am responsible for my own health, I will inform the facilitator of any relevant conditions and will address any discomfort during the session.

Today's Date
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