Health & Wellbeing Questionnaire

Thank you for your interest in breathwork.

Before we arrange your session, please complete the Health & Wellbeing Questionnaire below. The information you provide will help Sharon determine whether breathwork is suitable for you and ensure your experience is safe, supportive, and tailored to your individual needs.

Once submitted, Sharon will review your questionnaire and be in touch regarding the next steps.

*Medical Diagnosis Applicable List: Epilepsy, Heart Condition, High Blood Pressure, Breathing Disorder, Autoimmune Disease, Cancer, Diabetes, any contagious diseases, Glaucoma

First Name

Last Name

Email Address

Birth Date (MM DD YEAR)

Nationality

Have you been Hospitalized? Y/N

If you answered Y for Hospitalization, elaborate on reason and treatment. N/A if not applicable

Have you had any kind of Surgery? Y/N

If you answered Y for Surgery, elaborate on which kind and when? N/A if not applicable

Have you had any kind of Medical Diagnosis? Y/N

If you answered Y, please provide details (Refer to *MEDICAL DIAGNOSIS APPLICABLE LIST above)

Do you have any known Allergies? Y/N

If you answered Y for Allergies, please list them below. N/A if not applicable

Have you had any Mental Diagnosis? Y/N

If you answered Y to Mental Diagnosis, please list the Diagnosis and date? N/A if not applicable

Are you Pregnant? Y/N

If you answered Y to Pregnancy and are taking Medications? Please list them below. N/A if not applicable

Are you using Drugs? Y/N

Please list the Drugs and how often you use them? N/A if not applicable

Breathwork Participation Agreement

By submitting this form, I confirm that:

I understand that breathwork may bring up physical sensations, emotions, and personal experiences. Sessions may take place in a group setting and may include guided support from the facilitator.
I confirm that I have provided accurate information about my physical and mental health. I understand that certain health conditions may make breathwork unsuitable or require additional discussion before participation.
I understand that being open about my physical, emotional, and mental wellbeing helps ensure that any breathwork sessions are safe, appropriate, and tailored to my individual needs.
I accept responsibility for my participation and understand that breathwork is not a substitute for medical, psychological, or psychiatric treatment.
I agree to follow all guidance provided during the session and will inform Sharon of any changes to my health or wellbeing that may affect my ability to participate safely.
I understand that Sharon reserves the right to decline or discontinue participation if there are concerns about safety or suitability.

By submitting this form, I confirm that I have read, understood, and agree to the above.

All enquires are usually answered within 24 hours, and all contact is strictly confidential and uses secure phone and email services.

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Health & Wellbeing Questionnaire

Breathwork Participation Agreement