PRANIC APPS CONFIDENTIAL HEALING FORM

CONFIDENTIAL HEALING FORM
PERSONAL INFORMATION
Name:
Today’s Date: MM / DD/ 20 YY
Today's Date:

DayMonthYear
Date
E mail:
example@example.com
Date of Birth: MM /DD / 20 YY
Date of Birth:

MonthDayYear
Date
Occupation:
Address:
City:
State:
Zip Code:
Referred by:
Primary reason for today's visit:
Phone:
MEDICAL HISTORY
Do you take any prescription drugs?
if yes, specify:
Do you have a history of contagious disease(s)?
if yes, specify:
Do you have a history of serious physical injury?
if yes, specify:
Do you have a history of psychological disorder?
if yes, specify:
Are you pregnant?
YesNo
Other pertinent Medical History:
if yes, specify:
CLIENT’S INFORMATION
What is/are your present complaint(s)/diagnosis:
How long have you had this complaint(s)/diagnosis (Be specific):
Please describe present condition and/or symptoms:
Relevant Treatment History:
Using the scale below please indicate the current level of symptoms and circle the number BEFORE the Pranic Healing Session:

I, the recipient, understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist a medical professional is to be consulted immediately. I hereby release the person(s) providing Pranic Healing and the Pranic Healing organization from any liability as a result of the services received by me.
Client's Name (please print):
Client's Signature:

Clear
CONFIDENTIAL HEALING FORM
Client Name:
Date

MonthDayYear
Date
PRANIC HEALING SESSION
Please indicate affected areas/chakras
Healer's comments:
Using the scale below please indicate the current level of symptoms and circle the number AFTER the Pranic Healing Session:
NoneMildModerateSevere
Client's Comment (please print):
Instruction given to Patient (please print):
Healer's Name (please print):
Healer's Signature:

Clear
Case #:
ComplexPsychologicalSimple
Should be Empty:

CONFIDENTIAL HEALING FORM

PERSONAL INFORMATION

MEDICAL HISTORY

CLIENT’S INFORMATION

CONFIDENTIAL HEALING FORM

PRANIC HEALING SESSION