HOW TO USE THIS FORM

Fill the form directly in your browser. Fields expand automatically as you write, so nothing gets cut off.
For Gender, Yes / No questions, simply click an option to select it.
Signatures: draw directly inside the signature box using your mouse (or your finger on a touch screen).
Need more space? Use the “+ Add” buttons below the tables.
When complete, click Save as PDF at the top. In the print dialog choose destination “Save as PDF”, paper size A4, and enable Background graphics.
Auto-save: your case in progress saves itself on this device — you can close the browser and continue later. Only the current case is kept: after saving its PDF, press “Start new case” for the next patient. Use “Download backup” to move a case to another device.

CASE LABEL — USED AS THE PDF / BACKUP FILE NAME

Load backup

💡 How these buttons work & why to use them:

Save as PDF (top right button): Click when finished to download a printable PDF file of this patient's case sheet for submission.
Download Backup: Saves a master safety copy to your computer containing this patient's case PLUS your Healer Profile, Consent Signature, and Testimonial Index. Use this to transfer data or keep long-term backups.
Load Backup: Restores your entire setup (profile, consent, index, and case sheet) from a previously saved backup file.
Clear Form: Clears active case fields so you can start fresh for your next patient without affecting your Profile or Consent Signature.
🔄 Switch Healer / Master Reset: Use when multiple healers share the same laptop! Erases ALL stored data (Profile, Consent, Index, and Case Sheet) from this computer so a new healer can log in cleanly.

✨ Note: Everything you type is automatically saved in your browser as you write.

CONFIDENTIAL HEALING DATA SHEET

Case Type

Requirement for certification: 10 Simple · 10 Advanced · 5 Psychotherapy cases

Patient's Name

Age

Gender

Contact / WhatsApp

Occupation

Address Line 1 & 2

City

State

Zip / Pincode

PATIENT'S CONDITION

Medical Condition / Diagnosis

Symptoms

Eg. for Lower back pain : (1) pain in the lower back, (2) unable to bend forward (3) walking problem

Symptom 1 Symptom 2 Symptom 3 Symptom 4

DECLARATION

I understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it I hereby release the person or Institute for Pranic Healing and anyone from all liabilities as a result of the services received by me.

Signature of the Patient

draw with mouse or finger

Date

Name of the Healer

Healing Details

Basic Book Pg. No.

Advanced Book Pg. No.

Psychotherapy Pg. No.

SCANNING RESULTS - BEFORE & AFTER HEALING

U (underactivated) - O (overactivated) - N (normal) - C (congested) - D (depleted)

		Energy Level (C/D/N)		Activation Level (U/O/N)
		Before Healing	After Healing	Before Healing	After Healing

FEEDBACK FROM PATIENTS

Improvement measurement from the start on a scale of 0-10
0 means no-discomfort, 10 being quite severe

Healing No.	Healing Date
Healing No.	Healing Date	Scale (0-10)	Scale (0-10)	Scale (0-10)	Scale (0-10)

QUALITATIVE FEEDBACK

Qualitative Feedback from patients on important and relevant changes in condition to be recorded

Patient Feedback

Total Number of Healing

Date

Patient Feedback

Total Number of Healing

Date

Patient's Final Feedback

Total Number of Healing

Date

Signature of the Patient

draw with mouse or finger

HEALER'S UNDERSTANDING OF PROTOCOL USED

Summary of the chakras healed, colors used, protocol used, their effects and properties — and the insights you gained from the protocol

Healer's Understanding (in your own words)

Healer's Additional Comments

Total No. of Healings

Is the Healing Still Continued?

Last Healing Date

Last Feedback Date

Signature of the Healer

draw with mouse or finger

Finished this case? First Save as PDF (and a backup if you want one) — then start the next patient.

Starting a new case clears this one from the device after a confirmation.