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TRANSCENDENTAL BREATHWORK                                           MEDICAL FORM
This workshop is not appropriate for pregnant women, persons with cardiovascular problems, severe hypertension, some diagnosed psychiatric conditions, recent surgery or fractures, acute infectious illness or epilepsy.
Transcendental Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy or medical treatment.
If you have any doubt about whether you should participate, it is essential that you consult your physician or therapist as well as the workshop organizers before attending.
The answers to the following questions are to assist your facilitators, to adapt to your case,
and will be kept strictly confidential.
Please answer all questions as completely as possible – adding further information at the end of the form where there are any ‘yes’ answers:

Do you have a past history of, have you been diagnosed with, or are you currently experiencing any of the following:
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Email *
Cardiovascular disease, including heart attacks, any cardiovascular surgery or any cardiovascular symptoms , High blood pressure, Strokes, TIAs, seizures, or other brain or neurological conditions *
Required
Diagnosed psychiatric condition *
Required
Recent surgery *
Required
Present or current infectious or communicable diseases *
Required
Glaucoma *
Required
Asthma (if yes please bring your inhaler to the workshop *
Required
Have you ever been psychiatrically hospitalized? *
Required
Are you currently in therapy or involved in any type of support group? *
Required
Are you currently taking any type of medication? (if yes, please list) *
Required
Is there anything else about your physical or emotional status we should be aware of? *
Required
If you answer "yes" to any of these questions, it is essential that you explain your answer .Thank you
Please provide emergency contact information:
Name & Whatsapp  *
Please provide your WhatsApp number (incl country code)
*
PLEASE READ AND SIGN THE FOLLOWING STATEMENT:
I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good. ________________________________Signature : name Date Age gender . *
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