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Breathwave Intake Form (Individual Sessions)
I authorize Breathwave and the Associated Health Professionals to collect my personal and medical information as documented below. In addition, I authorize Breathwave and the Associated Health Professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my benefit and safety. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
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Email
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Your email
Please list any medications you are currently taking and their purpose.
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Your answer
Have you ever had any heart problems? If yes, please describe.
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Your answer
Have you had surgeries? If so, please describe.
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Your answer
Do you have any current injuries or painful areas in your body?
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Your answer
Please describe any mental health history or psychological treatment you have had, including anxiety, stress disorders, depression, panic attacks, psychosis, …
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Your answer
Do you practice meditation or any other mindfulness techniques? If yes, please describe the benefits and limitations as they relate to your purpose.
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Your answer
Do you use plant medicines or psychedelic substances? If yes, please describe the benefits and limitations as they relate to your purpose.
Your answer
Is there anything else going on with you that would be helpful for me to know?
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Your answer
Submitting this form with your Full Legal Name and "Yes, I agree" will serve as your electronic signature.
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Yes, I agree
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What is your Full Legal Name? (as it appears on your birth certificate)
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Your answer
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