Medical Release Form - Holotropic Breathwork Print E-mail

Holotropic Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. Holotropic Breathwork can involve dramatic experiences accompanied by strong emotional and physical release. 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.

If you have any doubt about whether you should participate, consult your physician or therapist. as well as the facilitators before attending.

The answers to the following questions are to assist your facilitators and will be kept strictly confidential. Please answer all questions as completely as possible.

Please answer yes or no to the following questions:

1. Do you currently suffer from or have a past history of any of the following:

  • Cardiovascular disease, including heart attacks?
  • High blood pressure?
  • Severe mental illness?
  • Recent Surgery?
  • Past or recent physical injuries, including fractures or dislocations?
  • Present or current infectious or communicable diseases?
  • Glaucoma?
  • Retinal detachment?
  • Epilepsy?
  • Osteoporosis?
  • Asthma (If yes, please bring your inhaler to the workshop)?

2. Are you currently pregnant?
3. Have you ever been hospitalized for medical reasons?
4. Have you every been psychiatrically hospitalized?
5. Are you currently in therapy or involved in any type of support group?
6. Are you currently taking any type of medication?
7. Is there anything else about your physical or emotional status we should be aware of?

If you answered "yes" to any of these questions, please explain or elaborate.



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. My general health, as far as I am aware, is good.

Signature ___________________________________ Date_______________ Age_____

Printed Name__________________________________