Breathwork Booking Request

Breathwork Booking Request
Name

First NameLast Name
Email
example@example.com
Type of Appointment
What date do you have in mind? (can be left empty)

MonthDayYear
Date
Any additional information I should be aware of, health issues or anything in particular you would like to address
FOR INDIVIDUAL 1:1 SESSIONS INQUIRIES:

Do you currently or in the past have experienced any the following - but not restricted to:

Heart disease, high blood pressure (not controlled with medication) or previously suffered a heart attack or stroke?

Are you pregnant?

Do you have mental health issues such as bipolar or schizophrenia?

Do you have any chronic pain or arthritis? yes no Do you suffer from epilepsy, seizures, fainting?

Do you have asthma, allergies or other breathing problems? (please bring your inhaler to the session)

Do you have any diabetes or uncontrolled thyroid conditions?

Diagnosis of aneurysm in the brain or abdomen?

Fibromyalgia, Chronic Fatigue, ME or Migraines?

Detached retina or glaucoma?

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?
If you have answered YES to any of the questions above, please provide some details, and make sure you have the go ahead from your medical healthcare provider before taking part in a breathwork session. If in doubt, please get in touch with me at breathmedicine@icloud.com.
Your answer:
Have you got any other question or comments?
Should be Empty: