• Pranic Healing Session Record

    CONFIDENTIAL CLIENT FORM
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Do you smoke?*
  • Do you drink alcoholic beverages?*
  • Do you have high blood pressure?*
  • Are you pregnant or trying to get pregnant?*
  • Do you take any prescribed drugs or medications?*
  • Do you have history of contagious diseases?*
  • Do you have a history of psychological disorder?*
  • Do you have a history of serious physical injury?*
  • Image field 26

  • Purpose of Treatment

    Symptoms, complaints, problems
  • Rate your pain/discomfort BEFORE the treatment.*

  • Comments AFTER Treatment

  • Rate your pain/discomfort AFTER the treatment.*

  • 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.

  • Clear
  • Should be Empty:
Select theme: