Ear Candling Client's Chart

Therapists Name:______________


Client Name Date of Treatment
Street Address City Postal Code
E-mail Fax
Home Phone Work Phone
Occupation Date of Birth
Referred By Family Doctor
Reason for Treatment
Have you had ear candling done before? When? Where?
Are you under medical treatment now? If yes, please give details
List of current medications and supplements: List environmental and drug allergies:
How would you rate your current health status? (Good, fair, poor)
Are you currently being treated by any other practitioners?
Do you wear a hearing aid? Have you had your ears cleaned before?

Check off any 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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