[NAME OF PRACTICE]

REGISTRATION FORM
(Please Print)
Today’s date: Form No:

PATIENT INFORMATION
 Mr.  Miss
Patient’s Last name: First: Middle:
 Mrs.  Ms. Photo

Marital status (circle one) Birth date: Age: Sex:

Single / Mar / Div / Sep / Wid / / M F
Street address: Adhar no.: Home phone no.:
( )
Area: City: State: Pin Code:

Occupation: Employer: Employer phone no.:

( )
Chose Center because/Referred Center by (please check one box): TV Show  Internet  News Paper
 Close to home/work  Family  Friend  Yellow Pages  Other
Other family members seen here:

CHRONOLOGICAL HEALTH HISTORY

This sort of health history helps to establish trends in a persons health that may be relevant to present conditions. Indicate
below any accidents, broken bones, falls, illness, hospitalization, surgeries and any emotional traumas such as death, loss
of jobs, divorces etc.
Age 1 to 5 Age 41 to 45
Age 6 to 10 Age 46 to 50
Age 10 to 15 Age 51 to 55
Age 16 to 20 Age 56 to 60
Age 21 to 25 Age 61 to 65
Age 26 to 30 Age 66 to 70
Age 31 to 35 Age 71 to 75
Age 36 to 40 Age 76 & more

Do you exercise regularly? Do you have any addiction?

How may hours do you sleep per Do you wake rested
night
How may hours do you work each Do you have shift work
day
What level of personal stress are Minimum / Average /
you experiencing right now Considerable / Unbearable

IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:
( ) ( )
The above information is true to the best of my knowledge. I am aware of the treatment process and providing my / patients reports and photograph for
convenience of distance healing

Patient/Guardian signature Date

HEAD NOSE & SINUSES  Tinnitus

 Dizziness  Chronic Sinusitis  Vertigo
 Headache  Frequent colds  Other
 Head injury  Infections 
 Migraine  Nose bleeds RESPIRATORY
 Other  Stuffiness  Asthma
  Other  Bronchitis
NEUROLOGIC   Chronic Cough
 Alzheimer MOUTH & THROAT  Difficulty in breathing
 Autism  Dental problem  Emphysema
 Cerebral Palsy  Difficulty in swallowing  Lung Problems
 Coma  Dryness  Pneumonia
 Dementia  Gum Problem  Shortness of breath at night
 Diabetic Neuropathy  Hoarseness  Shortness of breath when lying
 Epilepsy / Fits  Laryngitis  Spitting up blood
 Fainting  Loss of taste  Tuberculosis (TB)
 Involuntary movement  Mouth Ulcer  Wheezing
 Loss of Balance  Sore throat  Other
 Loss of Memory  Tonsillitis 
 Mental Retardation  Other GASTRO INTESTINAL
 Meningitis   Abdominal Pain
 Motor Neuron Disease NECK  Acidity
 Muscular Dystrophy  Goiter  Appendix
 Multiple Sclerosis  Lumps  Black, tarry stool
 Mental Retardation  Pain or stiffness  Blood in stool
 Numbness or tingling  Swollen glands  Bowel disease
 Paralysis / stroke  Other  Change in appetite
 Parkinson   Constipation
 Slow Learner CARDIO VASCULAR  Diarrhea
 Speech Problem  Angina  Fatty stool
 Tremors  Cardiac Arrhythmias  Fatty Liver
  Chest Pain  Food allergy
EYE  Coronary Artery Dieses  Gallbladder disease
 Blurring  Heart Attack  Gallstones
 Blind Spot  Palpitation, Fluttering  Heartburn
 Cataracts  Swelling in ankles  Hemorrhoids or Piles
 Dryness  Other  Hepatitis
 Double Vision   Hiatus hernia
 Discharge INFECTIONS  IBS
 Eye Pain  Chickenpox  Indigestion
 Glaucoma  Dengu  Jaundice
 Itching  Fever  Liver Cirrhosis
 Light Sensitive  Harpies  Nausea
 Macula Degeneration  HIV/Aids  Passing gas
 Redness  Influenza  Trouble swallowing
 Retinopathy  Malaria  Ulcerative Colitis
 Tearing  Measles  Vomiting
 Other  Swine flue  Vomiting blood
  Other  Ulcers
EARS   Other
 Discharge BREASTS 
 Dizziness  Heaviness BLOOD / LYMPHATIC
 Earache  Lumps  Anemia
 Excessive wax  Nipple discharge  Hemoglobin
 Impaired hearing  Pain (or tenderness)  High Blood Pressure
 Infection  Other  Low Blood Pressure
BLOOD / LYMPHATIC  Rashes CANCER
 Lymph node swelling  Other 
 Thalassemia  
 Triglyceride / Cholesterol ENDOCRINE 
 Other  Chronic Swollen Glands 
  Diabetes 
URINARY  Heat or cold intolerance 
 Bed wetting  Hormonal Imbalance 
 Blood in urine  Hypoglycemia 
 Chronic kidney disease  Thyroid trouble 
 Diabetic Nephropathy  Other 
 Frequency at night  
 Frequent infections MUSCULO SKELETAL BEAUTY & WEIGHT LOSS
 Increased frequency  Arthritis  Body Sculpting
 Inability to hold urine  Broken bones  Brest Enlargement
 Kidney stones  Backache / Lower back pain  Brest Reduction
 Pain on urination  Bamboo Spine  Pranic Facial
 Prostate Enlargement  Frozen Shoulder  Weight Reduction
 Reduced urine flow  Gout 
 Urinary Bladder problem  Joint Dislocation 
 Other  Knee Pain 
  Muscle spasms / Cramps 
MALE REPRODUCTIVE  Rheumatism 
 Hernia  Sciatica 
 Impotence  Sleep Disc 
 Premature ejaculation  Tennis Elbow 
 Testicular masses  Weakness 
 Testicular Pain  Other 
 Venereal disease  
 Other PEREPHERAL VASCULAR 
  Cold Hands / Feet 
FEMALE REPRODUCTIVE  Varicose Ulcer 
 Difficulty conceiving  Varicose Veins 
 Excessive flow  Other 
 Irregular cycles  
 Menopause EMOTIONAL 
 Number of Pregnancies  Addiction 
 Number of life births  Anger 
 Number of miscarriages  Anxiety 
 Number of abortions  Insomnia 
 Pain during intercourse  Irritation 
 Painful menses  Mood Swings 
 PCOD  Nervousness, Depression 
 Vaginal itching  O.C.D. 
 White discharge  Phobias 
 Other  Psychological problem 
  Tension, Stress 
SKIN  Trauma 
 Acne  Other 
 Boils  
 Dry Skin ALLERGIES 
 Eczema  
 Itching  
 Leucoderma / Vitiligo  
 Lumps  
 Night sweats  
 Psoriasis  

Chakra Congested / Normal / Depleted Over active / Normal / Underactive

Crown Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Forehead Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Ajna Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Back Head Minor Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Throat Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Secondary Throat Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Front Heart Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Back Heart Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Front Solar Plexus Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Back Solar Plexus Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Navel Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Meng Mein Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Front Spleen Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Back Spleen Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Sex Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Basic Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive
Perineum Minor Chakra  Congested  Normal  Depleted  Over active  Normal  Underactive

Minor Chakras
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
 Congested  Normal  Depleted  Over active  Normal  Underactive
Organs
Liver  Congested  Normal  Depleted
Stomach  Congested  Normal  Depleted
Small Intestine  Congested  Normal  Depleted
Large Intestine  Congested  Normal  Depleted
Left Kidney  Congested  Normal  Depleted
Right Kidney  Congested  Normal  Depleted
Left Lung  Congested  Normal  Depleted
Right Lung  Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted
 Congested  Normal  Depleted

PRESCRIPTION
Prescribed Healing 3 Times a Week for Next 2 Weeks
Suggested Forgiveness and Mercy Prayer During Healing

Patient Feedback Date : dd/mm/yyyy

Disease Improvement % Remark

Patient Feedback Date : dd/mm/yyyy

Disease Improvement % Remark

Patient Feedback Date : dd/mm/yyyy

Disease Improvement % Remark

Patient Feedback Date : dd/mm/yyyy

Disease Improvement % Remark

Patient Testimonial
Name
Address
Age
Occupation
Case

Healers
Period dd/mm/yyyy to dd/mm/yyyy
Testimonial

Signature

Signed On