A FEW QUESTIONS BEFORE WE GET STARTED

To help us create the best experience for you at our retreat, we kindly ask you to fill out the form below. The information you provide will assist us in tailoring the program to your needs and ensuring everything runs smoothly. All details you share will be kept confidential and will only be used for planning and administrative purposes. Your privacy is important to us, and we will not share your information with anyone without your consent. We appreciate you taking the time to help us prepare!

Personal Info

First name

Last name

Health related questions

Do you engage in any physical exercise? If so, what and how often?

Are you currently dealing with health issues? If so can you provide more info (onset, diagnosis, severity, and treatment).

Have you had any major illnesses, surgeries or accidents in the last 12 months? If so please provide more info

Are you currently taking any medication (prescribed by your doctor or bought over the counter)?

Is there any other reason, based on personal experience or medical advice, that could prevent you from performing yoga or breathwork without medical supervision?

Please tick any of the following that you currently suffer from or have suffered from in the past:

Multiple answers possible

Heart problems (chest pain, heart defects, high blood pressure, thrombosis, angina, arrhythmia, etc.)

Lung conditions (severe asthma or any breathing problems)

Excessive anxiety, post traumatic stress, depression

Panic disorders (or recent panic attacks)

Severe mental illness (schizophrenia, paranoia, psychosis)

Eye related diseases (glaucoma, detached retina)

Epilepsy

About your practice and goals

Please choose the option you feel best describes your relationship with breathwork:

Please choose the option you feel best describes your relationship with yoga:

Please choose the option you feel best describes your relationship with meditation:

Is there anything specific you’re hoping to gain or address attending this retreat?

Anything else you'd like to add before we start?

I confirm that the given information in this questionnaire is true and certify that I am in adequate physical, emotional and mental health to participate in Breathwork/Yoga sessions. I understand that whilst every care is taken, the facilitators will not be liable for any damage or injury resulting from my practice. Thank you for taking responsibility for yourself and your experience.