check

Medical Waiver

Please complete this questionnaire to gain access to your membership.

Click the button below to start.

Start

Question 1 of 8

Name?

Question 2 of 8

Have you ever done breathwork?

A

Yes

B

No

Question 3 of 8

If so, what was your experience? (if no, put N/A)

Question 4 of 8

Have you been hospitalized in the last 12 months?

A

Yes

B

No

Question 5 of 8

If yes, please explain. (If no put N/A)

Question 6 of 8

Is there any reason emotionally/physically you might not be a candidate for breathwork?

A

Yes

B

No

Question 7 of 8

Medical History. Select any or all that apply to you:

(Select all that apply)
A

Angina

B

Cardiovascular disease

C

High blood pressure

D

History of heart attack

E

Glaucoma

F

Osteoporosis

G

Retinal detachment

H

Pregnant

I

Previous injury or surgery

J

Take regular medications for a condition

K

History of panic attacks, psychosis or disturbances

L

Severe mental illness

M

Seizure disorders

N

Family history of aneurisms

O

Frequent dizziness or vertigo

P

None of the above

Question 8 of 8

Rate the following areas of your life on a scale from 1 - 5; 1 being not satisfied and 5 being fully satisfied. We will personally send you a customized list of practices in The Breath Channel that will be supportive to start with.

 

Relationship/Love

Money/Abundance/Work satisfaction

Spirituality/Connection to yourself

Anxiety/Fear/Stress

Energy/Motivation

Confirm and Submit