Consent & Medical History

Client Name

First

Last

list Sessions (name,

Email Address

Medical History (please list any diagnoses, conditions, medications, surgeries, or relevant medical history)

Breathwork Medical History Checklist

Cardiovascular issues (heart condition, high blood pressure, stroke/heart attack history)
Respiratory issues (asthma, COPD, breathing difficulties)
Neurological issues (seizures, epilepsy)
Pregnant or postpartum (recent)
Recent injury, surgery, or hospitalization
Mental health considerations (schizophrenia, bipolar, panic attacks, PTSD, severe anxiety)
None of the above

Emergency Contact (name, relationship, and phone number)