Breathwork Client Intake & Medical Form

Client Intake Form

1:1 Breathwork & Group Breathwork Sessions
NAME*
Date Of Birth*

MonthDayYear
*18+ Only
Address*

Street Address

Street Address Line 2

SuburbState / Territory

Post CodeCountry
Phone Number
Please enter a valid phone number.
EMAIL ADDRESS*
REFERRED BY
Did a friend refer you to us?
MEDICAL HISTORY
Do you have any current illnesses or conditions that may restrict your level of physical activity in the program? If NO - type N/A. If YES, please describe below:*
Are you being treated by a medical professional? If NO - type N/A. If YES, please describe below:*
Are you taking anti-depressant medications? If NO - type N/A. If YES, please describe below: *
Have you been under psychiatric care? If NO - type N/A. If YES, please note most recent date of care below: *
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING HEALTH CONDITIONS?

Manic depressionSchizophreniaMental illnessDepressionRecent SurgeryAsthma (medicationpresent)Blood Pressure (High)EpilepsyEmphysemaKidneyLung weaknessHeart diseaseHead injuries
IF YOU HAVE ANY OF THE ABOVE HEALTH CONDITIONS, PLEASE CONFIRM YOU HAVE SOUGHT MEDICAL ADVICE TO PARTICIPATE.

YES - My medical advisor has confirmed that I CAN participate.YES - My medical advisor has recommended that I CANNOT participate.N/A - I don't have any of the conditons above
Signature

Powered by Jotform SignClear
Should be Empty:

Client Intake Form