Personal Information

1. Name: 
2. Date of birth: 
3. Marital status: 
4. Children & Ages: 
5. Email: 
6. Phone number: 
7. Address: 
8. Profession:
9. Website: 

Goals and Experience

     1. Have you practiced Soma Breath or HeartMath techniques before? If yes:

1. 1. 1. How did you learn about them?
      2. How often do you currently practice?
      3. What has been your experience so far?

     2. What are your primary goals or intentions for these sessions?

1. 1. 1. Are you seeking physical benefits (e.g., improved energy, better sleep)?
      2. Emotional regulation (e.g., managing stress, cultivating calm)?
      3. Personal growth (e.g., connecting with intuition, clarity)?
      4. Stress management (one, several, or all of these)?
      5. Other (please specify):

     3. Do you have experience with any other types of breathwork?

1. 1. 1. If yes, please describe the type(s) of breathwork, how you learned them, and your experience with these practices.

     4. Are there specific outcomes you’re hoping to achieve through these practices?

Health and Background

1. Do you have any diagnosed medical conditions that might affect your breathing or heart rate? (e.g., asthma, hypertension, heart conditions, epilepsy, pregnancy)
2. Are you currently under the care of a healthcare professional? If yes, please provide details
3. Are you currently taking any medications that might impact your breathing, heart rate, or stress response?
4. Do you have a pacemaker?

Stress and Emotional Wellbeing

1. What is your current stress level on a scale of 1 to 10? (1 = very low, 10 = very high)
2. Have you experienced significant stress, anxiety, or emotional challenges recently that you’d like to address during these sessions?
3. Do you have any known triggers or areas of sensitivity that we should be mindful of during sessions?

Breathwork and Heart Rate Awareness

1. Are you currently using any breathing techniques or biofeedback tools (e.g., apps or devices)? If yes, please describe.
2. Do you have any challenges or concerns with breathing practices (e.g., discomfort with breath-holding, dizziness)?

Lifestyle and Habits

1. What is your current level of physical activity? (e.g., sedentary, moderate exercise, very active)
2. Do you have any routines or habits aimed at stress reduction or mindfulness? (e.g., meditation, yoga, journaling)

Consent and Confidentiality

1. Do you consent to participating in guided Soma Breath/HeartMath sessions and understand that these practices are not a substitute for professional medical or psychological treatment?
2. Do you agree to confidentiality regarding all personal information shared during sessions?
3. Have you read and understood our Terms and Conditions?