Tomatis Patient Intake Form – Adult

To ensure we provide you with the most effective and tailored experience, we kindly request that you complete this intake form. Your input will help us better understand your unique needs and goals, enabling us to craft a personalized program that best suits you.

Thank you for taking this crucial first step towards transformative change.

Tomatis Patient Intake Form – Adult Form
REASON FOR CONSULTATION
MEDICAL HISTORY
Have you received any other interventions or therapies?
Have you been diagnosed with a visual impairment?
Do you wear glasses?
Have you been diagnosed with an auditory impairment?
Which is your dominant hand?
Are you sensitive to fabrics/ textures?
Tags in clothing?
Are you overly sensitive in general?
Have you been involved in any accidents?
If yes please specify
Have you ever been hospitalized?
Have you had any of the following procedures?
Do you have a diagnosed seizure disorder?
ENT HISTORY (Please select all necessary, Do you do any of the following)
Are you prone to any of the following:
Have you had any problems with tonsils or adenoids?
Do you present with any of the following conditions (select all that apply)?
Are you overly sensitive to loud sounds or noises?
Do you hear sounds others don’t, or before others notice?
Are you able to pay attention in a noisy environment?
Do you frequently ask people to repeat what they say?
Do you find that you “tune out” or ignore sounds from the environment?
ALLERGIES/SENSITIVITES (Please select all necessary)
Do you suffer from food or environmental allergies or sensitivities?
Have you ever been tested for allergies?
Have you ever suffered from eczema?
Asthma?
Other rashes?
Yeast infections?
Do you suffer from gut issues?
Does anyone in your family suffer from any allergies or food intolerances?
SLEEPING HISTORY
Do you have difficulties with falling asleep?
Do you sleep through the night?
Do you wake at night?
GOALS

Jennifer Muller

Tomatis® Level 4 Consultant