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Neurodynamic Breathwork Medical Form

Moylan Ryan PLLC

MEDICAL INFORMATION AND RELEASE FORM

Neuro - Dynamic Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. Neuro - Dynamic Breathwork can involve experiences accompanied by very strong emotional and physical release. Breathwork is not appropriate for pregnant women, or for persons with severe cardiovascular problems, severe hypertension, severe mental illness, acute infectious illness. Breathwork would also not be appropriate in cases of recent surgery/fractures or

of epilepsy or various other conditions. If you have any doubt about whether you should participate, consult your physician or therapist, as well as your breathwork facilitators before attending. The answers to the following questions are to assist your facilitators and will be kept strictly confidential. Please answer all questions below as completely as possible.

Any “Yes” answers must be explained in detail on the following page.

Select all that apply

Select all that apply

Additional Medical and Emotional History

Have you been hospitalized for medical reasons within the last 10 years? (If yes, please describe)

Have you ever been hospitalized due to an emotional crisis (e.g. severe depression, suicidal thoughts or attempts, psychotic episode, or nervous breakdown)? (If yes, please describe in detail)

Are you currently in therapy or involved in any form of support group or practice? If yes, describe what kind and for how long:

Are you currently in taking any type of medication? If yes, please give names, dosage, and reason for taking it:

Is there anything else about your physical or emotional status we should be aware of?

Have you ever purposely injured yourself or somebody else?

On a scale from 10 to 1 (10 = very good health, 1 = very poor health), describe how you’ve been feeling in the past couple of months or weeks:

Emotionally

Emotionally

Physically

Physically

If you answered “yes” to any of the above questions, please elaborate or explain at the bottom of this form.

I understand that this Neuro-Dynamic Breathwork session is intended as a personal growth experience and should not be used as a substitute for psychotherapy.

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I understand that Neuro - Dynamic Breathwork could involve dramatic experiences

accompanied by strong emotional and physical release.

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In order to get the benefits of this breathwork session and to be safely grounded and ready to return home, all of the various pieces of the workshop (intro talk, breathing, sitting, sharing group, end of session integration talk) are very important. Because of this and also because I may have an expanded state of awareness experience, I understand that in order to be accepted to attend this workshop, I agree to stay for the entire event. If, despite the above, I still decide to leave the workshop without completing it, I understand and agree that (1) I will notify a Facilitator before leaving to receive any of the Facilitator’s instructions/directions which could minimize the consequences of early departure; and (2) in accordance with the "Release, Waiver, and Indemnity of Liability Agreement", I will be accepting full responsibility for any consequences of leaving early and release and waive any and all claims which I might have against Moylan Ryan PLLC in connection with my early departure.

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Please read and sign the following statement.

I hereby confirm that I have read and understood the above information and answered all questions completely and honestly, and have not withheld any information. If there are any changes in regards to the answers on this form between now and the time of the workshop, I will notify Moylan Ryan PLLC in writing immediately.My general health, as far as I am aware, is good.

Print Your Full Name

Signature

Signature

Date

Your Age

Your Phone Number

Your Email Address

(To be signed again on morning of workshop) By signing my name below and writing in today's date, I confirm that nothing has changed in regards to the answers on this form since I filled it out.

Signature

Signature

Date

Additional Comments or Details on any "Yes" Answers