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WHM Workshop
Breathwork
Workshop coming soon!!
Health Declaration Form:
Full Name *
Email *
Phone *
Date of your workshop *
Are you in good health? ex: can you play sports or go in a sauna without encountering any problems? *
yes
no
Do you, or have you ever suffered from any of the following conditions? *
heart disease
hypertension (high blood pressure)
hypotension (low blood pressure)
angina pectoris
epilepsy
Raynaud's Syndrome type ll
kidney failure
severe asthma
recently had an operation
migraines
schizophrenia
auto immune disease
any other serious medical conditions
none of the above
If you ticked 'any other serious medical conditions' please provide more information and consult your doctor if you have any questions before participation
Do you currently take medication for your heart *
yes
no
If you ticked 'yes' , please provide more info (what medication and what is it for)
Are you allergic to certain foods or substances? *
yes
no
If you selected 'yes' please describe which foods or substances you are allergic to
Are you currently pregnant? *
yes
no
Is there anything else your instructor should know?
I hereby declare that I completed this form accurately. I shall not hold Liviu Hrubariu or any of his assistants liable for any damages and/or injury resulting from participation in the WHM activity. My participation is voluntary and at my own risk. *
I agree
I confirm I am over the age of 18 *
Yes
How did you hear about Wim Hof Method event?
friend
facebook
instagram
o2-ice website
word of mouth
other
If you answered 'other' please give more info
I provide consent for my information to be used for the event I'm attending and understand I may occasionally be contacted about future WHM activities.(You can unsubscribe at any time). *
yes
Emergency contact. Please include the name and phone number for your emergency contact: *
Leave this field empty
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