Name * First Name Last Name Age * On a scale of 1 to 10, how would you rate your current stress levels? (1 being low, 10 being high): * Describe any major sources of stress or challenges in your life: * Breathwork Experience: Have you practiced breathwork before? Yes often No A little If yes (or a little), please describe your previous experience with Breathwork: Do you have any existing medical conditions we should be aware of? If yes, please specify: * Are you currently taking any medications? If yes, please list: * Have you had any recent surgeries or medical procedures? If yes, please provide details: * Have you ever tried cold immersion techniques before? If yes, what was your experience like? * Do you have any specific concerns regarding cold immersion? * Emergency Name and Contact Number: * By submitting this form, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that the provided information will be kept confidential and used solely for the purpose of tailoring breathwork coaching sessions to my individual needs. * Please type your digital signature: Thank you!
