PRANIC HEALING CLINIC SESSION RECORD

PRANIC HEALING SESSION RECORD
TO HELP US SERVE YOU BETTER, PLEASE FILL OUT THE FORM BELOW:
Name
First NameLast Name
Date:
MonthDayYear
Date
Street
Apt#
State
Telephone:
Age:
Email:
example@example.com
For your safety throughout the session please answer what is appropriate
Do you smoke?
Do you drink alcoholic beverages?
Do you have high blood pressure?
Are you pregnant or trying to get pregnant?
Please list any prescribed medication you are currently taking
Please list any diagnosed psychological concerns
Please list any recent history of or ongoing contagious disease
Please list any serious physical injuries
Purpose of visit, symptoms or concerns
If you are experiencing pain please rank 1-10; 10 being most pain ever experienced
Other Comments or Symptoms:
Please communicate Comments after the session with your healer
I understand that Pranic Healing is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, a medical professional is to be consulted. 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 received. I understand that this session record will be held confidential and may only be reviewed by the U.S. Pranic Healer Certification Board for the purpose of the Pranic Healer Certification Program.
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PRANIC HEALING SESSION RECORD