Vibroacoustic Therapy Intake Form
Autosaved at 12:04 pm on 02/16/2026
Indicates a required field
Name (First & Last) : ( of person receiving the therapy)
Date of Birth (mm/dd/yyyy):
Email:
Occupation:
Address:
Phone:
Emergency Contact Name & Phone Number :
Can we text you reminders for appointments ?
Yes
No
How did you hear about us?
What goals do you have for your Vibroacoustic Therapy Sessions?
Relieve Stress
Reduce Anxiety
Reduce Body Pain
Process Trauma
Process other
GENERAL HEALTH
What methods of relaxation do you practice in your daily life?
What 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 lying on your back?
Yes
No
Please list any accidents or surgeries in the last 3 years:
Do you have any metal implants, a pacemaker or body piercings ?
List any medications or supplements you are currently taking:
VIBROACOUSTIC THERAPY
Have you ever had Vibroacoustic therapy before? If so, when ?
HEALTH HISTORY
Please check all that apply :
Heart Condition
Psychiatric Disorder
Herpes/Shingles
High Blood Pressure
Low Blood Pressure
Numbness/Tingling
Sinus Problems
Allergies
Chronic Pain
Rashes
Jaw Pain/TMJ
Blood Clots
Headaches
Arthritis
Spasms/Cramps
Broken/Fractured Bones
Pregnancy
Fatigue/Sleep Disorder
Depression/Anxiety
Cancer
It is my choice to receive Vibracoustic Therapy and I understand that during the sessions there will be a gentle sound and vibration used on/around me. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update my practitioner of any changes to my health status. I understand that the practitioners of Coastal Wellness and Life Coaching Center do not diagnose illness, disease, or physical disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis and that it is recommended I see a primary health care provider for those services. I understand that I alone am responsible for informing my primary health care provider that I am receiving these sessions and inquiring as to whether they may adversely affect my current health condition.
