Breathwork Session Questionaire

Please answer the following questions provide as much information as possible and elaborate with more information if you answer ‘yes’

(Any personally identifiable information received is kept confidential. All personal information shared will only be shared as necessary for the welfare of the participants. Personal information collected is stored in a secure location and safely destroyed after it is no longer legally required.)

Personal Details *print please

Your FULL NAME(*)

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Phone(*)

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Email Address(*)

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Please indicate your date of birth: (*)

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Emergency Contact

Name(*)

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Relationship(*)

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Phone(*)

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Are you currently receiving regular support or medical supervision by a psychologist, psychiatrist or medical doctor? (*)

YESNO Invalid Input

If yes describe:

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Are you currently taking any prescribed medication?(*)

YESNO Invalid Input

If yes describe:

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Are you currently taking any non-prescription medication, including herbal or homeopathic preparations?(*)

YESNO Invalid Input

If yes describe:

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Have you experienced Breathwork?

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Do you have a good support system in your life, including individuals or groups?

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Other Experience

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Do you have a history of, or have you recently experienced any of the following?

Cardiovascular disease, including angina or heart attack(*)

YESNO Invalid Input

High blood pressure(*)

YESNO Invalid Input

Mental illness or psychiatric hospitalization(*)

YESNO Invalid Input

Surgery, inpatient or outpatient(*)

YESNO Invalid Input

Past or recent significant physical injuries

YESNO Invalid Input

Recent or current infectious or communicable diseases(*)

YESNO Invalid Input

Seizure disorder (epilepsy)(*)

YESNO Invalid Input

Osteoporosis(*)

YESNO Invalid Input

Diabetes(*)

YESNO Invalid Input

Back problems(*)

YESNO Invalid Input

Do you have asthma? (If yes, please bring your inhaler & alert us at the beginning of the workshop/session.)

YESNO Invalid Input

Have you ever, or are you currently experiencing any form of psychosis or severe neurosis?(*)

YESNO Invalid Input

Are you currently pregnant?(*)

YESNO Invalid Input

Are you currently in therapy or in a support group?(*)

YESNO Invalid Input

If you answered “yes” to any of these questions, please explain or elaborate below or alternatively explain in an email.

Medical details

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Is there anything else about your physical or emotional situation that we should be aware of?

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Do you agree not to consume any alcohol or drugs prior to or during your session/workshop?(*)

YES I agree not to consume any alcohol or drugs prior to or during your session/workshop Invalid Input

Please provide details about any potential concerns here, or anything you feel we should know

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Please read and tick to a agree to the following:

I understand that an individual Lottelife Breathwork™ is intended as a personal growth experience and should not be used as a substitute for psychotherapy. I understand that Lottelife Breathwork™ could involve dramatic experiences accompanied by strong emotional and physical release. Invalid Input

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. If I am submitting this form electronically, I agree that my typed name on the signature line below shall be the binding, legal equivalent of my actual signature.

I have read, understood, and have truthfully answered the above questions.

If I have indicated a potential concern, I have provided details.

Name (CAPITALS) (*)

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where did you hear about Lottelife?

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Signature(*)

Sign Above

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Date(*)

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Information and Resources

Lottelife Breathwork Session Questionaire

Emergency Contact

Do you have a history of, or have you recently experienced any of the following?

Please read and tick to a agree to the following:

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

Lottelife Breathwork Session Questionaire

Emergency Contact

Do you have a history of, or have you recently experienced any of the following?

Please read and tick to a agree to the following:

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

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