Breathing Space Intake Form Name Email Phone Date of birth Pronouns Please note any relevant medical history. (check all that apply to your recent or past health) Please note any relevant medical history. (check all that apply to your recent or past health) 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 are you seeking from this treatment? 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. Do you consent to hands on touch of your abdomen? (Avoiding the lower pubic area and breast tissue. *You will be professionally draped at all times.*) (Yes or No) Do you consent to hands on touch of your abdomen? (Avoiding the lower pubic area and breast tissue. *You will be professionally draped at all times.*) (Yes or No) Yes No Do you consent to hands on touch of your chest? (Avoiding the breast tissue. *You will be professionally draped at all times.*) (Yes or No) Do you consent to hands on touch of your chest? (Avoiding the breast tissue. *You will be professionally draped at all times.*) (Yes or No) Yes No Submit