Health Form

Health & Safety

Health Declaration

Please complete this form honestly before your first session. All information is confidential and used solely to ensure your safety.

Personal Information

Health Conditions

Please indicate if you have or have had any of the following:

Heart or circulatory system conditions*
Unregulated high or very low blood pressure*
Epilepsy or history of seizures*
Asthma*
Serious psychiatric disorders (psychosis, untreated bipolar)*
Recent surgery or serious injury (past 6 months)*
Pregnancy*
Glaucoma*
Advanced osteoporosis*

Previous Experience

Have you done breathwork before?

Consent

I confirm that the information provided is accurate. I understand that 9D Breathwork is an intense somatic experience and I take full responsibility for my participation. I have read the contraindications and confirm I have no conditions that would prevent safe participation.

⚠️ Liability Waiver: I understand that 9D Breathwork involves intense physical and emotional experiences. I voluntarily participate and fully release SHIELD, its facilitators, and Jakub Latosi from any liability for injury or adverse effects arising from my participation.