PRANIC HEALING CONFIDENTIAL CLIENT FORM

PRANIC HEALING CONFIDENTIAL CLIENT FORM
To Help us serve you better, please provide the following information.

We respect your privacy.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Phone
Email Address
example@example.com
Address
City
State
Zip
Occupation
Whom may we contact in case of emergency?
Relationship of emergency contact?
List Prescription Medications
List all Allergies and how you react to them
Personal History supporting a safe Pranic healing Session:
Do you smoke?
If former smoker, when did you stop?
Do you drink alcoholic beverages?
If yes, please specify how many drinks per week:
Other drug use?
If former, when did you stop?
History of contagious disease?
If yes, please specify:
History of Psychological Disease
If yes, please specify:
History of serious physical injury?
If yes, please specify:
History of Cancer?
If yes, please specify:
History of high blood pressure?
If yes, please list your last blood pressure reading:
Are you pregnant or could be pregnant?
If yes, when is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PRANIC HEALING CONFIDENTIAL CLIENT FORM
PURPOSE OF SESSION(S)
Please list Concerns you would like addressed with Pranic Healing
Rate your concern now:
(Scale of 0-10): 0 = no concern 5 = moderate concern 10 = unbearable
Other Comments:
I agree to email and text message appointment reminders
I understand that Pranic Healing is not intended to replace conventional medicine but rather to complement it. I understand I am not receiving medical advice during Pranic Healing ses sions. If symptoms persist, a medical professional is to be consulted. I understand Pranic Healing Practitioners are not licensed by a governing body. I understand that my session records will be held confidential yet not bound by HIPAA as Pranic Healers are not medical providers. I hereby release the person(s) providing the Pranic Healing Session and the U. S. Pranic Healing Center from any liability as a result of the services and sessions I have re ceived.
Signature of client
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PRANIC HEALING CONFIDENTIAL CLIENT FORM

PRANIC HEALING CONFIDENTIAL CLIENT FORM

PURPOSE OF SESSION(S)