Resonant Chamber Client Intake Form

Your Details

Full Name *

Date of Birth *

Height

Weight (lbs)

Telephone — Home

Telephone — Work

Telephone — Mobile

Email *

Address

City

Province

Postal Code

Emergency Contact & Personal

Emergency Contact Name

Relation

Emergency Phone

Relationship Status

Spouse / Partner Name

Number of Children

Occupation

Do you enjoy your job?

YesNo

Why You Are Here

Primary reason for seeing us

Have others helped you with the problem?

What are your expectations after the sessions?

Who can we thank for your being here (who referred you)?

Conditions Experienced

Check any conditions below that you have experienced. Use the dropdown beside each to indicate whether it is current (C) or past, over a year ago (P).

Your Visit

Describe any specific medical attention or assistance you will need while visiting our centre

Will you be bringing a caregiver, nurse or spouse with you?

Current state of health

Wellbeing & Lifestyle

What brings you joy?

Most emotionally draining relationship in your life

Is your home environment peaceful or stressful most of the time?

Do you have trouble concentrating, or `brain fog'?

YesNo

Do you feel supported?

YesNo

What drives you, inspires you, gives you a sense of purpose?

Emotions that best reflect how you feel most of the time

JoySadExcitedOptimisticAngerDepressedPassionateTerrifiedResentmentHopelessSafeAnxiousPeacefulDespairCalmAloneHappyBlissfulAfraidFrustrated

Do you adhere to any particular diet?

Average hours of sleep per night

Do you drink filtered or purified water?

YesNo

Describe your exercise / activity routine

Are you sensitive to light / loud noise?

YesNo

If yes, please explain

Are you in fear regarding your health?

How ready are you to make the lifestyle changes, the diet changes and the attitude changes that may be necessary to good health?

I have read the above information and have filled out the form to the best of my knowledge. I understand that the questions on this form are being asked in order to better assess my current circumstances and their relationship to my wellbeing. I further understand that I am voluntarily agreeing to have a relaxation therapy session and that no medical claims or promises of healing have been given.

I have read and agree to the statement above.

Signature (type your full name) *

Date *

Confidential Client Application

Your Details

Emergency Contact & Personal

Why You Are Here

Conditions Experienced

Your Visit

Wellbeing & Lifestyle