Date *

When did you provide this live therapeutic music session?

MM

DD

YYYY

Age

Under 18 (pediatric patient)

18 or older (adult)

Sex

Male

Female

Unknown

Pre-session observations *

Select as many observations as you were able to make. Do not check the box if you were unsure.

Patient presented as alert, oriented, and responsive

Patient presented as awake

Patient presented as confused/disoriented

Patient presented as non-responsive

Patient presented as sleeping

Patient presented as intubated

Patient presented as actively dying

Patient presented with a tight facial expression (furrowed brow, clenched jaw)

Patient presented with clenched hands

Patient presented with a tightened body position (curled up)

Patient presented with repetitive movements

Patient presented as smiling

Patient presented crying

Patient presented moaning

Patient presented with Cheyne-Stokes breathing

Other (include in the pre-condition notes)

Other observations

Check all that apply.

Visitor(s) present

Patient is hard of hearing

Language barrier

Television on: muted

Television on: with sound

Loud equipment or other noises

In medical isolation: I had to use protective equipment that affected my playing/singing

In medical isolation: I could not be as close to the patient as I would normally play/sing

Telehealth: Session was provided virtually

Interruptions during music session

Something else prevented me from providing a typical music session (specify in the pre-condition notes)

Type(s) of music used

Check all that apply.

Recognizable tunes

Tunes the patient did not recognize (e.g., unfamiliar or improv)

Fast tempo (>70 bpm)

Medium tempo (50-70 bpm)

Slow tempo (<50 bpm)

Strictly metered

Loosely metered

Unmetered

Post-session observations *

Select as many observations as you were able to make. Do not check the box if you were unsure.

Session ended with patient alert, oriented, and responsive

Session ended with patient awake

Session ended with patient confused/disoriented

Session ended with patient non-responsive

Session ended with patient sleeping

Session ended with patient intubated

Session ended with patient actively dying

Patient passed away during session

Session ended with patient having a tight facial expression (furrowed brow, clenched jaw)

Session ended with patient having clenched hands

Session ended with patient in a tightened body position (curled up)

Session ended with patient having repetitive movements

Session ended with patient smiling

Session ended with patient crying

Session ended with patient moaning

Session ended with patient having Cheyne-Stokes breathing

Other (include in the post-session notes)

Your name *

Providing your name serves as your electronic signature, indicating that the information provided here is true and accurate to the best of your knowledge.

First Name

Last Name

HIPAA PII confirmation *

The information provided in this form does not violate HIPAA standards. I did not include any personally identifiable information about the patient.

Permission confirmation *

I have permission from this healthcare facility to use this form.

Integrity confirmation *

The information I provided is in accordance with my certification program's code of ethics and my facility's code of conduct.