Raaga Music Therapy

1. Name

Date of Birth

Place of Birth

Gender

Phone Number

Email Address

Date of Assessment

Doctor’s name/or treatment facility’s Name

2. 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

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

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

5. In general, how is your health?

A. Feel upset, if something happens unexpectedly or things don’t go as planned?

B. Feel, are you unable to control important things in your life?

C. Feel nervous, anxious or stressed?

D. Not being able to stop or control worrying?

E. Feel little interest or pleasure in doing things?

F. Feel tired or have little energy?

G. Have trouble falling or staying asleep or waking up too early?

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

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

A. Did you listen to music as recommended?

If no, please give reason.

B. Did you listen to music alone or with someone?

C. Do you feel any change in your mood, stress or energy level? If yes, please explain:

D. Is there any change in your blood pressure or medicines since the start of using RMT? If yes, please explain:

E. Have you noticed any change in your sleep pattern, since the start of RMT? If yes, please explain:

F. Would you like to continue receiving RMT after 3 weeks course?

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

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

Raga Music Therapy - Patient Assessment