First Name*

Last Name*

Birth Date*

Date

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number*

Country Code Area Code Phone Number

Email*

example@example.com

Do you smoke?*

Yes No

Do you drink alcoholic beverages?*

Yes No

Do you have high blood pressure?*

Yes No

Are you pregnant or trying to get pregnant?*

Yes No

Do you take any prescribed drugs or medications?*

Yes No

If "Yes", specify.

Do you have history of contagious diseases?*

Yes No

If "Yes", specify.

Do you have a history of psychological disorder?*

Yes No

If "Yes", specify.

Do you have a history of serious physical injury?*

Yes No

If "Yes", specify.

Rate your pain/discomfort BEFORE the treatment.*

What would you like to be the focus of your treatment?*

Please, specify all relevant symptoms.

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

Rate your pain/discomfort AFTER the treatment.*

How do you feel AFTER the Pranic Healing treatment?*

Please, share any relevant comments regarding your experience.

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

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*

Clear

Please verify that you are human*

Pranic Healing Session Record

Purpose of Treatment

Comments AFTER Treatment