Spiritual Assesment

Client Information

Full Name

Date of Birth

Phone / Email

Practitioner Name

Date of Assessment

Purpose

This form helps identify common signs that may indicate sihr (magic), ‘ayn (evil eye), or hasad (envy). Please check (✔) any symptoms you experience frequently or severely.

1. Physical Symptoms

Heavy feeling in the shoulders or knees

Constant fatigue or laziness

Feeling ill but doctors find no cause

Frequent stomach bloating

Chronic constipation or persistent diarrhea

Stomach inflammation

Frequent boils, pimples, or unusual skin breakouts

Dark spots or melasma on the face

Excessive hair loss

3. Social & Behavioral Symptoms

Dislike of studying or inability to focus

Loss of interest in work

Aversion to marriage or rejection of potential spouses

Problems in the home or wanting to leave the house often

Strong dislike between husband and wife or frequent arguments

Marital intimacy problems (e.g., inability to perform)

Hatred between family members (parents, siblings, etc.)

Spending long periods in the bathroom

Enjoying sitting in darkness

Spiritual Symptoms

Difficulty praying or maintaining regular prayer

Feeling heavy during worship

Shortness of breath at night or when hearing Qur’an

Strong desire to wander or be lost

Aversion to Qur’an recitation or Islamic gatherings

Other Signs

Predicting events before they happen

Seeing shadows, figures, or illusions at home

Rapid blinking of eyes without reason

Feeling heat, cold, or tingling in face or body

Instructions

-Tick all symptoms you experience regularly.

-If you checked more than 10-15 symptoms, it may indicate spiritual imbalance — consult a trusted ruqyah practitioner or scholar for guidance.

Practitioner Notes & Recommendations

Client Acknowledgement

Client Signature

Date

Disclaimer: This form is for informational purposes only and is not a substitute for medical diagnosis or treatment. Always consult a qualified healthcare professional for medical concerns.

Spiritual Assesment

Healing Touch Academy – Spiritual Health Self-Assessment Form

Client Information

Purpose

Instructions

Client Acknowledgement