Medical Questionnaire
Please fill in this form before participating
Sign in to Google to save your progress. Learn more

Neurological: Have you had a brain surgery or do you suffer from a significant head injury, have you ever suffered a stroke or severe migraine?:


*

Psychological: Have you ever been diagnosed with bipolar disorder, schizophrenia or previous psychiatric condition? Have you been hospitalised any psychiatric condition or emotional crisis within the last 10 years Or do you have any other medical, psychiatric conditions which would impair or affect ability to engage in any activities that involve intense physical and or emotional release? 

*

Cardiovascular: Has your medical practitioner ever told you that you have a heart condition or have you ever had a heart attack, heart surgery, arrhythmias or hypertension?

*

Pulmonary: Has your medical practitioner ever told you that you have Pneumothorax, lung disease, emphysema, pulmonary oedema?

*

Asthma: Do you have a history of asthma attacks?

(If you are asthmatic, you are welcome to attend providing you bring your inhaler to the session


*

Epilepsy: Do you have a history of epilepsy?


*

Pregnancy: Are you pregnant or suspect you might be?

*

Eyes: Has your medical practitioner ever told you suffer: detached Retina and or Glaucoma?


*

Ears: Do you have perforated eardrums, permanent tubes in ear-drums or suffer hearing loss in one or both ears or had ear surgery?


*

If you have answer YES to any of the questions above, you will be reuired to provide evidence of meidcal fitness to facilitators, relevant to the positive medical disclosure from a qualifed healthcare professional. 

Failure to address answering YES to any of the above conditions prior to engaging in breathing, breath holding or cold-water imersion (also referred to as ice baths) activities, may endanger your haelth as well as the safety of other participants. 

*
Required
Please write your name *
Please write your email *
Please write today's date *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy