Twin Dragons Martial Arts - Qi Gong Research Form

Twin Dragon’s Martial & Internal Research Paper

Student’s Name____________________________ Last Name _______________________________

Home Phone # ____________________Birth Date _________________Today’s date_____________

Doctor’s Name __________________________________ Diagnosis dated_____________________

Summary of Pathology/Condition/Sickness/Diagnosis________________________________________

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Treatment/Procedures recommended by doctor___________________________________________________________________________

How do you feel Qi Gong/Reiki has help to your recovery _________________________________________________________________________________

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Has your condition (s) improve positively since you started Qi Gong? Yes No

Explain____________________________________________________________________________

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Current Conditions _________________________________________________________________________________

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Note: Please include any document that can validate the condition diagnosed by doctor (before and after)