Raaga Music Therapy

B. What is your Medical Diagnosis? (Select all applicable options)

Hypertension (High blood pressure)
Diabetes Mellitus
Thyroid disorder (Hyper or Hypothyroidism)

Cancer (any type)
Coronary Artery Disease
Stroke and/or Dementia

C. How long have you been diagnosed with the illness noted above?

E. Do you take medication(s) for the conditions noted above? If yes, how many?

Mental & Emotional Status
F. Please answer the following questions about your feelings/emotions in the last 3-4 weeks. Select 0=Never, 1=Sometimes, 2=Often, 3=Most of the time

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. How often did you have trouble controlling your anger?

5. Not being able to stop or control worrying?

7. Felt little interest or pleasure in doing things?

9. Felt hopeless or that you let yourself or family down?

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

11. To what extent you consider your sleep problem interferes with your daily chores or mood?

12. You felt worried about your sleep problem?

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

G. Have you tried Natural therapy (Ayurvedic, naturopathy, meditation or Yoga) for your condition? If yes, please explain which therapy and for how long?

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

Indian
Western
Pop

Classical
Devotional
Movie Songs

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

c. Do you have any background in classical music (circle all applicable)?

Training
Practicing
Teaching

d. Which classical music type will you like to listen to?

Please send a signed NDA after submitting this form. You can download the NDA document here .

Click here to download the Client Assessment Form and NDA. After completing the forms, please scan and email them to info@raagamusictherapy.org.

Raga Music Therapy - Client Assessment

Mental & Emotional Status F. Please answer the following questions about your feelings/emotions in the last 3-4 weeks. Select 0=Never, 1=Sometimes, 2=Often, 3=Most of the time

Mental & Emotional Status
F. Please answer the following questions about your feelings/emotions in the last 3-4 weeks. Select 0=Never, 1=Sometimes, 2=Often, 3=Most of the time