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Breathwork Intake Form

Initial Breathwork Intake form for working with Lila Heller.

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Question 1 of 19

First and Last Name

 

Question 2 of 19

Email

Question 3 of 19

Phone number

Question 4 of 19

Emergency Contact Name

Question 5 of 19

Emergency Contact Number

Question 6 of 19

Your Physician's Name (if applicable)

Question 7 of 19

Your Physician's Contact Number (if applicable)

Question 8 of 19

Have you ever done breathwork prior to this program?

Question 9 of 19

If so, when? And with whom? What was your experience like?

Question 10 of 19

Do you have any traumatic experiences or any other information you would like me to be aware of? If yes, please explain. 

Question 11 of 19

Have you been hospitalized in the last 12 months?

Question 12 of 19

If yes, please explain:

Question 13 of 19

Is there any emotional or physical reason you may not be a good candidate for breathwork? If so, please explain. 

Question 14 of 19

Have you had OR do you presently have any of the following conditions? (Check if yes.)

(Select all that apply)
A

Angina

B

Cardiovascular disease

C

Heart attack

D

High blood pressure

E

Glaucoma

F

Retinal detachment

G

Osteoporosis

H

Seizure disorders

I

Recent injury or surgery

J

Any condition for which you take regular medications

K

History of panic attacks, psychosis, or disturbances

L

Severe untreated mental illness

M

Family history of aneurysms

N

Frequent dizziness or vertigo

O

Are you currently pregnant?

P

Other

Question 15 of 19

If you selected Other, please specify here: 

Consult Your Physician

If you have answered “Yes” to one or more of the above questions, you must consult your physician before engaging in meditative breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Question 17 of 19

By signing here you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our program based upon the answers given.

Question 18 of 19

Printed Name

Question 19 of 19

Date

Confirm and Submit