Holotropic Breathwork, Medical information
Holotropic Breathwork™ is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. Holotropic Breathwork™ can involve experiences accompanied by very strong emotional and physical release. This workshop is not appropriate for pregnant women, or for persons with severe cardiovascular problems, severe hypertension, severe mental illness or acute infectious illness.  

There are other situations for which we ask you to obtain a written release from your doctor. These situations include recent surgery/fractures, epilepsy, glaucoma and retinal detachment. If this applies to you we will let you know what you can share with your doctor regarding the nature of this work so that your doctor can give you an informed consent.  We have found that doctors are generally willing to do this.

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

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

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First and last name *
When filling out this form any "yes" answer must be explained in detail.
Do you have a past history or currently suffer from any of the following?
Cardiovascular disease including heart attacks *
if yes to Cardiovascular, please give details
High blood pressure *
if yes to high BP, please give details
Diagnosed Psychiatric Condition *
if yes to psychiatric condition, please give details
Bipolar Disorder, Manic Disorder or Schizophrenia                   *
if yes to above, please give details
Recent surgery *
if yes to recent surgey, please give details
Past or recent fractures *
if yes to fractures, please give details
Past or recent injuries or dislocations *
if yes to injuries, please give details
Glaucoma *
if yes to glaucoma, please give details
Retinal detachment *
if yes, please give details
asthma *
if yes to asthma, please give details
osteoporosis *
if yes to osteoporosis, please give details
epilepsy *
if yes to epilepsy, please give details
currently pregnant *
Hospitalization
Have you been hospitalized for medical reasons within the last  20 years?. If no, please write "no" in the field below.

If yes to hospitalization, please describe. *
Psychiatric hospitalization
Have you ever been hospitalized due to an emotional crisis
(this could include severe depression, suicidal thoughts or
attempt to commit suicide, a psychotic episode or nervous
breakdown)? If no, please write "no" in the field below.

If yes to psychiatric hospilatization, please describe. *
Therapy
Are you currently in therapy or involved in any form of support
group or practice? If no, please write "no" in the field below.


If yes to therapy, please describe. *
Medication
Are you currently taking any type of medication?                              
If yes, please give names, dosage and reason for taking it. If no, please write "no" in the field.


If yes to medication, please describe. *
Infectious deseases
Do you have any present or current infections or communicable diseases? If no, please write "no" in the field.

If yes to infections, please describe. *
Anything else?
Is there anything else about your physical or emotional status that we should be aware of? If no, please write "no" in the field.

If there is anything else, please describe. *
We cannot send your confirmation letter until we've received this medical information and any needed release from your doctor.   Please fill out and submit as soon as possible.  Upon successfully submitting this form you will see a window stating that your response has been recorded.
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