Date
*
When did you provide this live therapeutic music session?
MM
DD
YYYY
Type of facility
Hospital
Hospice
Private home
Skilled nursing or memory care home
Rehabilitation facility
Outpatient treatment center (cancer infusion, dialysis)
Other (describe in the notes below)
Location state/country
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
US territories
Canada
Mexico
Asia
Australia
Central America
Europe
South America
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)
Pre-session notes
Provide any details for items where you selected "Other" above. Is there anything else we should know about your observations of the patient before you started the session?
Instrument(s) used
*
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
Music session notes
Is there anything else you observed during the session that affected your music?
Other measurements
If any other measurements were available before and after the session, detail them here.
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)
Post-session notes
Provide any details for items where you selected "Other" above. Is there anything else we should know about your observations of the patient after you ended the session?
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.