File No :

1. Name :

2. Age :
3. Sex : Male / Female
4. Address :

Town / City :
State :
Zip / Pincode :
5. Home phone :
6. Work phone :
7. Cell phone :
8. E-mail :
9. Occupation :
10. Present medical condition :

11. Past medical history :

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12. Purpose of visit :

13. What is your treatment goal? :

14. Do you have any infection? : Yes / No

If yes, please specify

15. Are you pregnant? : Yes / No / Not applicable

16. Do you have menstrual : Yes / No / Not applicable periods?

17. Have you ever had organ : Yes / No transplant?

If yes, please specify

18. Do you have any metal : Yes / No implants?

If yes, please specify

19. Will you be able to continue the : Yes / No

number of healing sessions as

recommended?

20. Do you prefer distant healing or :

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 direct healing?

21. How did you hear about us? :

Mark 'X' on the area of pain / discomfort

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------------------------------------------ FOR OFFICIAL USE ONLY ----------------------------------------

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 Pranic healing diagnosis

22. Chakras Depletion / OA/ UA* Normal

congestion
Front solar plexus

Back solar plexus

Front heart

Back heart

Basic

Sex

Navel

Meng mein

Throat

Sec throat

Ajna

Forehead

Crown

Back head

Jaw minor

Hip minor

Knee minor

Sole minor

Armpit minor

Elbow minor

Palm minor

*O A - Over activation U A – Under activation

23. Any other findings :

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24. Treatment goal
Short term goal :

Long term goal :

25. Treatment plan

Duration of treatment :

Number of treatment :

sessions / week

Name of the client : Signature :

Date :

Name of the healing practitioner : Signature :

Date :