Pranic Healing Session Intake Form

First Name*

Last Name*

Birth Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Country CodeArea CodePhone Number

Email*

example@example.com

Do you smoke?*

YesNo

Do you drink alcoholic beverages?*

YesNo

Do you have high blood pressure?*

YesNo

Are you pregnant or trying to get pregnant?*

YesNo

Do you take any prescribed drugs or medications?*

YesNo

If "Yes", specify.

Do you have history of contagious diseases?*

YesNo

If "Yes", specify.

Do you have a history of psychological disorder?*

YesNo

If "Yes", specify.

Do you have a history of serious physical injury?*

YesNo

If "Yes", specify.

Rate your pain/discomfort now.*

What would you like the focus to be for your session?*

Please, specify all relevant symptoms.

Are there any other comments or symptoms you would like to share?

Upload a recent photo of your face.*

How did you hear about our services?

Who should we thank for the referral?

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.

Signature*

Please verify that you are human*