Questionnaire - Wholehearted Breathwork

Breathwork intake questionnaire

Completion of this questionnaire is mandatory.
Please submit before your first breathwork session.
Thank you.

Name *

First

Last

Email *

Phone *

Do you currently have (or have had in the past) any long term health conditions? *

Yes
No

Health conditions details

Are you currently taking any prescription medication? *

Yes
No

Medication details

Is there anything that may affect your participation in breathwork? *

Yes
No

Participation details

Have you been cleared by a medical professional to participate in breathwork? *

Yes
No (and I choose to participate)

Please add any additional information (if required)