Whate is the main source of stress in your life.

Do you have any sensitivity to sound or vibration?

Yes

No

Do you have any difficulty laying on your front or back?

Yes

No

Please Explain which side and this issue?

Please list any accidents or surgeries in the last 2 year.

Do you have any metal implants a pacemaker or body piercings?

List the medications you are currently taking.

Have you ever had a singing bowl massage before? if so when?

is there any area of your body you do not want the bowls to be placed?

Do you have any allergies?

Health history?

Relaxation / Pain Relief / Stress Reduction / Other(explain)

Are You Currently under the care of a doctor or physician?

Have you informed your primary care provider that you are receiving Sound Vibrational Therapy session?

Yes

No

Are you currently using any additional techniques to manage stress?

Desired Date and Time

Paid Amount

Payment mode

Cash

Cheque

Credit Card

Debit Card

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