Breathwork Medical Information Form

Breathwork Medical Information Form
Please check the boxes below to certify that you do not have any of the following contraindications to practicing activated breathwork:
I am not currently pregnantI do not have a detached retina or glaucomaI have not been diagnosed with high blood pressure, cardiovascular disease, irregular heart beat, prior heart attack, or any other cardiovascular conditionI have never had a stroke, seizure or other brain/neurological condition or disease including but not limited to epilepsyI do not use perscription blood thinnersI have no family history of aneurysmsI have not been diagnosed with osteoporosisI have no recent physical injuries that are still healing and could be re-injured through intense movementI have not been diagnosed with bipolar disorder, schizophrenia, or other psychiatric conditionI have not been hospitalized for a psychiatric conditionI have not been diagnosed with asthma or COPD or other pulmonary disorders.I understand that I am responsible for making my breathwork facilitator aware of any changes to the answers I provided on this form as they arise when participating in upcoming or future sessions.If you have any other medical condition that could be exasturbated by active breathwork please identify it next to the below box.Other
*This style of breathwork has the potential to be physically, emotionally, and/or mentally stressful. The goal is personal growth and heightened well-being. If there is any other pertinent medical/mental-health information you would like your facilitator to be aware of, please add it below.

*Your participation in this and future breathwork sessions and any medical information you provide is of your own free will. For your own safety, the safety of other participants, and your facilitator, you certify with your signature below that all information provided is true and correct.

*If you have any of the above contraindications, you must provide proof of consultation and medical clearance from your doctor in writing before participating.

*If you have any questions about contraindications, please email: sara@sod-inc.net
Name

First NameLast Name
Date of Birth

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Date
Email Address
example@example.com
Client's Signature

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