Double-Helix Breathwork Precautions & Liability Forms

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Double-Helix Breathwork Facilitator(s) Name:

Contraindications to Breathwork:

Respiratory Issues – COPD / Asthma – I have inhaler nearby.
Heart condition / Cardiovascular Issues
Epilepsy or history of seizures
Aneurysm
High Blood Pressure – not controlled by medication.
History of Stroke
Glaucoma / Vision Issues – eg., Retinol Detachment
Pregnancy or Breastfeeding
Recent Surgery
Osteoporosis
Uncontrolled Thyroid Conditions and/or Diabetes
Heavy Medication
Bipolar Depression / Psychosis - Prior diagnosis of bipolar disorder, schizophrenia, or previous psychiatric condition. - Hospitalization for any psychiatric condition or emotional crisis within the last 10 years. Any other medical, psychiatric, or physical conditions which would impair or affect ability to engage in any activities that involve intense physical and/or emotional release.
Mental Illness - Breathwork is great at helping manage several mental illnesses, including anxiety, depression, and PTSD. However, it should never be treated as a cure for mental illness. Those with a severe mental illness should work with their doctor to determine if breathwork would be helpful as part of their healing. While some greatly benefit from exercises, others might experience negativity when practicing them.

I acknowledge that I have read the above list of Contraindications to Breathwork.*

I HAVE NONE OF THE HEALTH CONDITIONS AS LISTED ABOVEYES, I HAVE ONE OR MORE OF THE HEALTH CONDITIONS AS LISTED ABOVE - I will discuss with the facilitator - I will participate with extra precaution, using Double Helix Breathwork nasal only and I will not hold my breath in Kumbhaka.YES, I HAVE ONE OR MORE OF THE HEALTH CONDITIONS AS LISTED ABOVE - I choose to not participate and request a refund of ticket price.

DOUBLE-HELIX BREATHWORK PRECAUTION FOR PREGNANT WOMEN.*

I AM NOT PREGNANTYES, I AM PREGNANT - I will only breath through the nose using Perfect Breath (5 seconds inhale / 5 seconds exhale), and I will not hold my breath in Kumbhaka.

Double-Helix Breathwork precautions for persons with recent surgeries, severe brain, blood, eye injuries or conditions.*

I HAVE NO RECENT SURGERIES OR HEALTH CONDITIONS AS LISTED ABOVEYES, I HAVE HAD RECENT SURGERY OR HEALTH CONDITIONS AS LISTED ABOVE - I will participate using Double-Helix Breathwork nasal only and I will not hold my breath in Kumbhaka.

Double-Helix Breathwork precautions for persons with severe mental disorders.*

I HAVE NO SEVERE MENTAL DISORDERSI HAVE A HISTORY OF SEVERE MENTAL DISORDERS - I will participate using Double-Helix Breathwork nasal only.I HAVE A HISTORY OF SEVERE MENTAL DISORDERS - I prefer to participate using Double-Helix Breathwork mouth breathing with extra precaution.