9D Breathwork In...
9DBreathworkIntakeQuestionnaire
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Full Name*
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Email*
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example@example.com
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Your answer
What style of breathwork have you tried before, if any?*
*
If you have a specific issue you'd like to work on, please specify.*
*
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Your answer
Health & Safety Screening*
Please check any that apply to you.
(Select as many as you like)
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Heart disease or heart condition
High or low blood pressure
Recent heart attack or cardiac surgery
Asthma or breathing difficulties
Chronic respiratory conditions
Currently experiencing severe depression or anxiety
History of severe mental health issues
Active suicidal thoughts
Currently pregnant
Recent major surgery (within last 3 months)
Seizure disorder or epilepsy
History of fainting
Are you currently taking any medications?
*
If so please list below.
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Your answer
Current State*
How are you feeling today?
(Select as many as you like)
How are you feeling today?
Great - ready for the experience
Good - some stress but manageable
Okay - dealing with some challenges
Struggling - having a difficult time
How would you rate yourstress level today? (1-10)*
10 = max stress
Your answer
Overall emotional
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stability? (1-10)
*
10 = ultra stable
Physical Energy levels? (1-10)
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10 = peak strength
How ready are you to go deep? (1-10)
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Do you have support people in your life?
(Select as many as you like)
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Yes - close friends/family
Yes - therapist or counselor
Limited support
Feeling isolated
Is there anything about
your physical or mental
health, any concerns
about the upcoming
session, or anything that
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would help you feel most safe and supported that you'd like me to know?"
*
Release of liability (type "I agree" below)
*
I/we prioritize the safety and well-being of all our participants, and as part of our commitment to ensuring a secure environment, we require the completion of this Liability Waiver Form. A breathing session may not be suitable for you if you have the following conditions: Cardiovascular problems, abnormally high blood pressure, aneurysms, epilepsy and seizures in the past, anyone taking heavy medication, severe psychiatric symptoms especially psychosis or paranoia, bipolar, osteoporosis, recent surgery, glaucoma or is currently pregnant. People with asthma should bring their own inhaler and consult with their physician and breathing session instructor before
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