Breathwork Form. Name * First Name Last Name Email * Date Of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Breathwork experience? Have you done Breathwork before? * Yes No How was your experience? What do you want to get out of this experience? What to bring Please bring along a yoga mate, a blanket and some water. Health & Wellbeing How do you rate your current health and wellbeing? * Great Good Average Struggling / Need help Have you had any major surgery or injuries? Please describe * Do you have any problems or issues with your body now, or recently? If so, describe history of illness * Breathwork Contraindications Do you suffer from any of the following? * Asthma High blood pressure History surgery or physical injury Thyroid condition Diabetes History of seizures Bipolar disorder, schizophrenia, or psychiatric condition Actively using recreational drugs or medication that alters brain chemistry - painkillers, anti-depressants, anti-anxiety, stimulants, hallucinogens, etc. Recent surgery or recent physical injury PTSD None of these apply to me I agree that the above information is correct and true Yes or No * Yes No Thank you!
