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HEALTH CHECK FOR BREATHWORK PARTICIPANTS

Birthday
Month
Day
Year
1. Do you have any of the following: Cardiovascular disease, including angina or heart attack
Yes
No
High blood pressure
Yes
No
A family history of aneurisms
Yes
No
A personal history of mental illness or psychiatric hospitalization
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Surgery, inpatient or outpatient
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Past or recent significant physical injuries
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Recent or current infectious or communicable diseases
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Glaucoma
Yes
No
Retinal detachment
Yes
No
Seizure disorder (epilepsy)
Yes
No
Osteoporosis
Yes
No
Back problems
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Sleep problems (apnea, snoring, etc.)
Yes
No
Dietary restrictions (vegetarian, gluten-free, etc.)
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

2. Have you been advised (by a doctor or other health care provider) to restrict your physical activity in any way?
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

3. Do you have asthma? (If you do, please bring your inhaler and call our attention to it at the workshop.)
Yes
No
4. If you are a woman, are you pregnant?
Yes
No
5. Are you currently in therapy or in a support group?
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

6. Are you currently taking any medication?
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

7. Do you have any other physical problems?
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

8. Is your general health good?
Yes
No
9. Is there anything else about your physical or emotional situation that you would like us to be aware of?
Yes
No

Put NA If you answered no to the previous question. PLease provide details if you answered yes.

Confirm by signing here that you have understood and completely answered all questions. Thank you.

Date
Month
Day
Year

Thank you for helping us keep all our participants safe. We will be in touch soon.

© 2013 by Ronit LeMon

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