Raaga Music Therapy

A. a. Name *

b. Date of Birth *

c. Gender *

d. Phone Number *

e. Email Address *

B. In general, how is your health? *

1. Felt upset, if something happens unexpectedly or things don't go as planned? *

2. Felt, you are unable to control important things in your life? *

3. Felt nervous, anxious or stressed? *

4. Had trouble relaxing or staying focused? *

5. Felt little interest or pleasure in doing things? *

6. Felt tired or having little energy? *

7. Had trouble falling or staying asleep or woke up too early? *

8. Did you feel pain, anywhere in your body? (0=No pain, 1=Mild pain, 2=Moderate pain, 3=Severe pain) *

9. Do you have any issues with your digestive system? (Select all applicable options)?

Constipation
Bloating of abdomen

Diarrhea
Stomach cramps

Digestive severity Rating

a. What type of music do you like to listen (Select all applicable)?

Indian
Western
Pop

Classical
Devotional
Movie Songs

b. How often do you listen to music for pleasure? *

Connect With Us
Raaga Music Therapy
6315 Adirondack Court,
Gainesville VA-20155(USA)
reach out to us
indy.shah@raagamusictherapy.org (USA) info@raagamusictherapy.org (USA)

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