MEDICAL SURVEY FORM

For Participation in Holotropic Breathwork


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

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

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



This medical form must be received by your workshop organizer as part of your registration. We cannot send your confirmation letter until we have received your medical form.

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