Name

Email

Phone

Date of birth

Pronouns

Please select if you have or have had any experiences with any of the following: Please select if you have or have had any experiences with any of the following: Pregnancy Seizures Stroke Heart conditions Auto-immune conditions Cancer Shortness or breath Asthma Anxiety/depression Insomnia High/low blood pressure Diabetes type 1 or 2 Osteoporosis Arthritis Serious injury

Do you use tobacco or cannabis? Do you use tobacco or cannabis? No Daily Weekly Monthly Former user

Do you drink alcohol? Do you drink alcohol? No Daily Weekly Monthly Former user

Are you currently taking any prescription medication? If yes, please note.

Are you currently taking any natural supplements? If yes, please note.

Have you had any surgeries in the past 5 years? If yes, please note.

Average hours of sleep per night:

How would you rate your current stress levels? (1-10, 10 being high) How would you rate your current stress levels? (1-10, 10 being high)12345678910

How would you rate your current physical health? (1-10, 10 being great) How would you rate your current physical health? (1-10, 10 being great)12345678910

How would you rate your current mental health? (1-10, 10 being great) How would you rate your current mental health? (1-10, 10 being great)12345678910

What is your inhale capacity? (3-15 seconds?)

What is your exhale capacity? (3-15 seconds?)

Do you have any experience with breathwork? If so, please explain.

Have you ever practiced breath retentions? (yes or no)

Tell me something that you love about yourself.

Tell me something that you are working to love more of.

Please specify what inspired you to commit to these breathwork sessions.

Do you have any specific physical, emotional, or energetic goals that you are hoping to work on?

What is your primary intention for these sessions?

Do you have any questions or concerns before getting started?