Medical Information Form

Please read the following information. If you have any questions, please check with one of the facilitators.
(This form is confidential)

your full name(*)

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Holotropic Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. The Breathwork process can involve a deep experience accompanied by powerful emotional and physical release as well as gentle sensations. Each session and experience are individual and unique.

This workshop is not appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.

The answers to the following questions are to assist your facilitators and will be kept strictly confidential.

In order for us to provide support and to create the container for the HB setting for this experience, please answer the following questions and provide as much information as possible.

If you answer ‘yes’ to any of the questions below and need to provide further information use the information fields below or please send more information in a separate email]

Personal Details

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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Phone(*)

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Would you like to receive the Lottelife Newsletter?

YES

NO

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where did you hear about Lottelife?

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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(*)

YES

NO

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High blood pressure(*)

YES

NO

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Mental illness or psychiatric hospitalization(*)

YES

NO

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Surgery, inpatient or outpatient(*)

YES

NO

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Past or recent significant physical injuries

YES

NO

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Recent or current infectious or communicable diseases(*)

YES

NO

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Glaucoma(*)

YES

NO

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Retinal detachment(*)

YES

NO

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Seizure disorder (epilepsy)(*)

YES

NO

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Osteoporosis(*)

YES

NO

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Diabetes(*)

YES

NO

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Back problems(*)

YES

NO

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

YES

NO

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Are you currently pregnant?(*)

YES

NO

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

YES

NO

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Have you ever, or are you currently experiencing spiritual emergency?(*)

YES

NO

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Are you currently taking any medication?(*)

YES

NO

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Is your general health good?(*)

YES

NO

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Have you experienced Holotropic Breathwork before?(*)

YES

NO

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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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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

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

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PLEASE READ AND INITIAL THE FOLLOWING STATEMENTS(*)

YES I understand that this Holotropic Breathwork™ workshop is intended as a personal growth experience and should not be used as a substitute for psychotherapy.

YES I understand that Holotropic Breathwork™ could involve dramatic experiences accompanied by strong emotional and physical release.

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

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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 and the digital signature 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.

Holotropic Breathwork™

HOLOTROPIC BREATHWORK™ MEDICAL INFORMATION FORM

Personal Details

Emergency Contact

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

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

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