Ear Candling Client's Chart Therapist: ___________________

Client's Name Today's Date
Address City Postal Code
Fax: E-Mail:
Home Phone Work Phone
Date of Birth Occupation
Referred by Family Doctor
Reason for Treatment:
Have you had ear candling done before? When? Where?
Under medical treatment now? If yes; please give us some details:

List of Current Medications & Supplements:

List Environmental & Drug Allergies:
How would you rate you present current health condition? Excellent Good Poor
Are you currently being treated by other practitioners?

Do you wear a hearing aid? Have you ever had your ears cleaned before?

Check off any of the symptoms you are currently experiencing or have experienced in the past:

Ear Aches Swimmer's Ear Allergies Sore Throats
Ear Discharge Headaches Migraines Sinus Problems
Loss of Hearing Ringing in Ears Buzzing Snoring
Excessive Ear Wax Sinusitis Dizziness Balance Problems
Ear Tubes Punctured Ear Drum Sinus Infections Ear Infections

Disclaimer: The ear candle practitioner does not make any claim of replacing any holistic or medical therapy. This therapy is of a complimentary nature only, rather than a curative treatment in itself. Information exchanged during any ear candling session is educational in nature and should be used at your own discretion. All client information is held in strict confidence. This is an 'Old Home Remedy'; the person receiving the treatment assumes full responsibility. The manufacturer or sellers of the candles are not liable for any claims, costs or damages resulting from the use of the candles.

I certify that the above information is correct to the best of my knowledge. I will not hold the Ear Candler responsible for any results or for any errors or omissions that I have made in the completion of this form. I understand that this service is designed to be a health aid and in no way takes the place of a doctor's care when it is indicated.

Client's Signature of Consent for Treatment: _____________________________________________________________________

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