Due to the nature of some exercises, it is required to have a few additional informations about possible symptoms, difficulties and illnesses prior to sessions. Please note that all of the information that you send through this form is strictly for the purpose of your individual session or workshop. The information will not be shared with a third party. If you prefer to fill in and print out a pdf form, please send me an email.







    Do you have some of the following:








    Please indicate the level of severity of any of the symptoms that you experience in list below:
    0 = None, 1 = Mild, 2 = Moderate, 3 = Severe






















    Nijmegen Questionnaire


    Please indicate the level of severity of any of the symptoms that you experience in the list below:
    0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very





















    Release of Claims, Assumption of Risk and Indemnification

    OXYGEN RESEARCH INSTITUTE LTD, Breathing to health, Martina Reiter

    By sending this form you will be agreeing to certain restrictions on your legal rights. Please read it carefully before sending. Please feel free to consult with your own attorney before.