Health intake form

Please complete this form fully before each session.
The information helps me prepare the session in a safe and appropriate way for you.

If anything changes regarding your health between submitting this form and your session, please let me know before we begin.

Thank you for your cooperation.

First name

Last name

Email address

Phone number

Emergency contact (Name & phone number)

Do you have any of the following medical conditions?*

Cardiovascular conditions

High blood pressure (uncontrolled)

Epilepsy

Bipolar disorder, schizophrenia, or other psychiatric conditions

Pregnancy

Asthma (if yes, please bring your inhaler)

Detached retina or glaucoma

Diagnosed aneurysm (brain or abdominal)

Psychiatric hospitalization within the last 10 years

Other medical conditions:

I confirm that the information provided in this form is complete and accurate to the best of my knowledge

I understand that breathwork is a physical practice and that I am responsible for fully disclosing any relevant health information.

I agree to inform the facilitator of any changes in my health status prior to the session.

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