Health Screening Breathwork

Health Screening Breathwork

It is essential to provide your breathwork instructor with all relevant information pertaining to the questions contained within this form. The information supplied by you is used to assist your breathwork instructor in making decisions about the type of breathwork that is suited to your personal needs. A positive answer does not automatically exclude you from participating.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Age*
Tell me about your experience with breathwork and what you are wanting to achieve as a result of participating in a group or 1:1 session.
Are you pregnant or suspect you may be?*
If you answered yes to the question above, how many weeks are you? (N/A if not applicable)*
Have you been diagnosed with glaucoma or detached retina?*
Have you had brain surgery or a significant head injury or experienced a severe migraine? *
Do you have a history of high blood pressure?*
If you answered yes to the question above, is your blood pressure currently under control with the use of medication? (N/A if not applicable)*
Have you been diagnosed with cardiovascular disease including angina, previous heart attack or stroke? Please provide details or N/A if not applicable.*
Has a medical practitioner ever told you that you have pneumothorax, lung disease, emphysema, pulmonary oedema?*
Have you been diagnosed with a thyroid condition?*
If you responded yes to the above question, is you condition currently controlled with medication? (N/A if not applicable) *
Have you been diagnosed with diabetes?*
If you responded yes to the above question, is you condition currently controled with medication? (N/A if not applicable)*
Have you been diagnosed with or are you prone to asthma? It is still possible for you to attend a breathwork session but it is essential for you to bring your inhaler.
Do you have a history of epilepsy?*
Do you have perforated ear drums, permanent tubes in ear drums, hearing loss, in one or both ears or had ear surgery?*
Have you received a prior diagnosis for bipolar disorder, schizophrenia or other psychiatric condition? Have you been hospitalised for any psychiatric condition or emotional crisis within the last 10 years?*
If applicable, please provide details of any other physical or medical conditions which would impair or affect your ability to engage in any activities that involve intense physical or emotional release? (N/A if not applicable)*
Failure to provide the relevant information to your breathwork instructor may endanger your health and the health of other participants. It is your responsibility to provide any information that may impact your ability to participate in breathwork activities.

Please sign below to confirm that you have provided all required information and any additional information that may impact your ability to participate in breathwork sessions.
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