CONFIDENTIAL HEALING DATA FORM Application ID CONFIDENTIAL HEALING DATA FORMSelect the Type of service required ( Office Use Only) Basic Pranic Healing Advanced Pranic Healing Pranic Psychotherapy Ancestral Healing Pranic Vastu Sastra Pranic Feng Shui Hypnotherapy Patient's Name* Address* Date Of Birth* MM slash DD slash YYYY Ocupation Phone*Email Sex* M F O Martial Status* Single Married Other Please answer the following questions:1) Do you smoke?* Yes No Rarely 2) Do you take any prescription drugs?* Yes No (If yes, specify) 3) Do you drink alcoholic beverages?* Yes No Rarely 4) Do you have history of contagious disease?* Yes No (If yes, specify) 5) Do you have history of serious physical injury?* Yes No (If yes, specify) 6) Do you have history of Psychological disorder(s)?* Yes No (If yes, specify) PATIENT'S CONDITION(Symtoms,Coplaints andProblems)*Patient's PhotoAccepted file types: jpg, jpeg, png, gif.Date* MM slash DD slash YYYY Healers Name Consent* I agree to the policy.I understand that Pranic Healing is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, medical professional is to be consulted.I hereby release the person or persons providing the Pranic Healing from any liability as aresult of the services received by me.