Pranic Healing: Client Session Form For Free Online Healing Events Phone The following form is required for all free recipients of our Pranic Healing sessions regardless of client status. Fields marked with a red asterisk are required. Please note that this form is not HIPPA compliant. If you wish to complete it via a secure portal, please visit our client portal login linked in the footer on the home page of this site. Nevertheless, we look forward to serving you. Sincerely, ~the divinely preserved healer team CLIENT FORM TITLE: Choose One: Mr. Ms. Mrs. Prof. Dr. Today's Date: * FIRST NAME: * LAST NAME: * MAILING ADDRESS: EMAIL ADDRESS: * BIRTH YEAR: CITY: STATE/PROVINCE: - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE: CONTACT NUMBER (Primary): PHONE NUMBER TYPE (Primary): Cell Work Home ALTERNATE CONTACT #: PHONE NUMBER (Alternate): Cell Work Home HEALTH ASSESSMENT 1. Do you smoke? * Yes No 2. Do you drink alcoholic beverages? * Yes No 5. Do you take any prescribed drugs/medications? * Yes No 6. Do you have a history of contagious diseases? * Yes No 7. Do you have history of psychological disorders? * Yes No 8. Do you have a history of serious physical injury? * Yes No 3. Do you have high blood pressure? * Yes No 4. Are you pregnant or trying to get pregnant? * Yes No --- If YES to #5, please specify: --- If YES to #6, please specify: --- If YES to #7, please specify: --- If YES to #8, please specify: REASON FOR SESSION Share any symptons, complaints, or other problems here: (9) Rate Your Pain/Discomfort Now: (scale of 0 to 10_ * 1 0 = No Pain, 5 = Moderate, 10 - Unbearable (10) Other Comments or Symptons: 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 Sesion 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. By submitting this form electronically, 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 Sesion 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. # * reCaptcha
