Pranic Healing Session Record Client Form
First Name:
*
Last Name:
*
Date
*
Street Address and Apt #
City
State
Zip Code
Phone Number
*
Age
*
Email
*
example@example.com
Do you smoke?
*
Yes
No
Do you drink alcoholic beverages?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Are you pregnant or trying to get pregnant?
*
Yes
No
Do you take any prescribed drugs/medications?
*
Yes
No
If yes, specify:
Do you have a history of contagious diseases?
*
Yes
No
If yes, specify:
Do you have a history of psychological disorder?
*
Yes
No
If yes, specify:
Do you have a history of serious physical injury?
*
Yes
No
If yes, specify:
Rate your Pain/Discomfort Before Session: (scale of 0 to 10): 0 = No Pain; 5 = Moderate Pain; 10 = Unbearable:
*
Other Comments or Symptoms:
*
Rate your Pain/Discomfort After Session: (scale of 0 to 10): 0 = No Pain; 5 = Moderate Pain; 10 = Unbearable:
Other Comments or Symptoms:
Signature of Client:
*
Date:
*
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