CONFIDENTIAL HEALING FORM

Initial Session (Intake)

PERSONAL INFORMATION

Name: Today’s Date: MM / DD / 20 YY

E-mail: Date of Birth: MM / DD / 20 YY

Address: Occupation:

City: State: Zip Code: Referred by:

Primary reason for today’s visit: Phone: ( )

MEDICAL HISTORY

Do you take any prescription drugs? Yes No if yes, specify:

Do you have a history of contagious disease(s)? Yes No if yes, specify:

Do you have a history of serious physical injury? Yes No if yes, specify:

Do you have a history of psychological disorder? Yes No if yes, specify:

Are you currently pregnant? Yes No if yes, specify: _____ # of weeks

Other pertinent Medical History:

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:

0 1 2 3 4 5 6 7 8 9 10

NONE MILD MODERATE SEVERE

DISCLAIMER:

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: _____________________________

CONFIDENTIAL HEALING FORM

Initial Session (Healing)

Client Name: ___________________________________ Date MM / DD / 20 YY

PRANIC HEALING SESSION Please indicate affected areas/chakras

Before Healing Session Healer's comments:

After Healing Session Healer's comments:

Specific Protocol Used:

Using the scale below please indicate the current level of symptoms and circle the number AFTER the Pranic Healing Session:

0 1 2 3 4 5 6 7 8 9 10

NONE MILD MODERATE SEVERE

Client’s Comments:

Instructions given to Client:

Healer’s Name (please print): ___________________________ Healer’s Signature:___________________________

Case #: ______ Simple Complex Psychological