Reiki Client and Treatment Record Form

First Name

Last Name

Phone

Select an Address

Address

Clients occupation

Where did you first hear about me?

Date of first session

Do you smoke?

Any conditions for which a diagnosis has been given; any health concerns; general state of health:

Your medical history (operations; accidents; injuries; serious illnesses; allergies)

Why would you like to receive reiki? What would you like Reiki to help you with?

Has anyone in your immediate family been diagnosed with heart disease, diabetes or cancer?

Do you drink alcohol?

Amount and quality of sleep?

Do you wake up rested?

Do you like your work (job/place/people etc)?

Energy levels (on scale from 0-10):

Pregnancies?

Relationship?

Happy in your relationship?

Do you exercise regularly?

Structural issues, spine:

Name, address and contact number of GP?

Emergency contact name and number

Are you happy for essentail oils or incense sticks to be used during your healing session?

Date

I confirm that the information given in this form is true

Your Signature

Thanks for submitting!

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