Questionaire:

Please fill in as much as possible, type your name as your digital signature and submit at least 24 hours before your scheduled session.

Kind regards,

Gemma Douglas.

Name

First Name

Last Name

Phone

(###)

###

####

Age

Life Situation (Pregnant, Children, Employment etc)

On a scale of 1 to 10, how would you rate your current stress levels? (1 being low, 10 being high):

Briefly describe any major sources of stress or challenges in your life:

On average, how many hours of sleep do you get per night?

Do you experience any difficulties with sleep? If yes, please describe:

Breathwork Experience: Have you practiced breathwork before?

If yes (or a little), please describe your previous experience with breathwork:

Meditation Experience: Have you practiced meditation before?

If yes ( or a little) please describe your previous experience with meditation:

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:

What do you hope to get out of this session?

Any questions?

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.