Registration Form Distant Pranic Healing Name Phone Number Email ID Date of Birth Height Weight Occupation Address Sex Male Female Marital Status Married Single Please mention if you have any ailments Do you smoke? Yes Rarely No Do you take any drug or prescribed medicines Yes No Do you drink alcohol? Yes Rarely No Do you have a history of contagious disease(s)? Yes No If yes, please specify Do you have a history os psychological disorder? Yes No If yes, please specify Have you had cancer of any kind? Yes No If yes, please specify Are you pregnant Yes No Do you have high blood pressure? Yes No PURPOSE OF VISIT (Symptoms, Complaints, Problems) PRANIC TREATMENT UTILIZED Accept 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 to be consulted. I hereby release the person or persons providing the Pranic Healing from any liability as a result of the services received by me. Submit