True Breathing Intake and Waiver Form
Please reach out with any questions you may have about this form or breathwork with Michael Jorge of True Breathing.
Full Name
First Name
Last Name
What is your age?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the symptoms that you're currently experiencing:
Anxiety
Headaches
Sleep Apnea
Depression
Respiratory
Panic Attacks
Chest pain
Asthma
Cardiac disease
Lymphatic
Gastrointestinal
Weight gain
Weight loss
Muscle Pain
High blood pressure
Low blood pressure
Anemia
Migraines
Brain fog
Other
Fluid Retention
Epilepsy
Diabetes
Hypertension
High Cholesterol
Other
The science of breath is open for all to learn about. However, please be aware that there are some contraindications for reduced breathing itself. Many of these conditions can be helped or even revered by increasing cellular oxygen levels through reduced breathing, but the process must be applied in a controlled manner so as to not raise carbon dioxide levels too quickly. Please reach out if you have any questions about these conditions.
Pregnancy
Cardiac disease
Currently in cancer treatment
Angina
Cardiac Arrythmia
Recent Stroke
Recent Thrombosis
Severe Renal Failure
Sickle-Cell Anemia
Recent Aneurysm
High Cholesterol
Schizophrenia
Recent Thrombosis
Do you have any allergies (environmental, medication, etc.)
Yes
No
Not Sure
If yes to allergies, please list:
Are you currently taking any medications or supplements?
Yes
No
If yes to medications or supplements, please list:
What are you hoping to gain from improving your breathing?
Please share what your current goals are, what you hope to improve in your overall wellness, or any other personal details you would like to share to help me better understand your situation.
Sign Waiver
Please sign below if you agree that: You are voluntarily participating in coaching with True Breathing. You understand the risks associated with reduced breathing if you have any of the contraindications listed above. You understand your breathing educator cannot prescribe a medical treatment or medications. Breathing training does not take the place of medical treatment and when in doubt you should consult your doctor. You agree you have stated all medical conditions, treatments, medications or information required to complete an informed breathing training session and you will keep the educator updated on any changes to information prior to future sessions. You therefore declare that all information supplied will be true and correct to the best of your knowledge. Please sign below:
Signature
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