Somatic Breath Journey - Client Consultation

SOMATIC BREATH

Client Waiver Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Mobile Phone

Phone Number
Preferred Method of Contact

E-mailPhonetext
Emergency Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHigh Blood PressureHypertrophyBlood ClotsCancerCardiovascular DiseaseCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDetached RetinaDepressionDiabetesGallbladder DiseaseGERD (Reflux)GlaucomaHepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseKidney DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you smoke cigarettes?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Are you currently taking prescription medication?

YesNo
If so, which medication and how often do you take?
Have you had any surgeries in the last 12 months?

YesNo
If yes, please specify:
Are you pregnant? How many weeks?
Why are you wanting to experience this work?
What would you like to get out of your journey?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Reason for seeking help
Average hours of sleep per night
Have you tried any other therapies such as hypnotherapy, reiki, kinesiology?
Additional comments or concerns
*Your signature below indicates that you have read the contraindications form and the information you have provided above is truthful.
Date
Signature

Clear
Should be Empty:

SOMATIC BREATH

Emergency Contact Information

Medical History