Blue Magic Alchemy - Medical Confirmation and Release

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Do you have a past history or currently suffer from any of the following?

Cardiovascular disease including heart attacks:

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High blood pressure:

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Diagnosed psychiatric condition:

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Recent surgery:

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Past or recent physical injuries including fractures/dislocations that are not fully healed:

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Glaucoma:

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Retinal detachment:

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Epilepsy (if yes, pls describe in detail below)

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Asmtha (if so, please bring inhaler):

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Prior diagnosis by Healthcare Professional of Bipolar Disorder, or Schizophrenia:

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Osteoporosis that is serious enough that intense movement could cause physical injury:

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Strokes, seizures or other brain/neurological condition:

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History of aneurysm in immediate family (children, siblings or parents):

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Are you currently pregnant:

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Have you been hospitalized for medical reasons within the last 10 years:

Yes

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(If yes, please describe below):

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Have you ever been hospitalized due to an emotional crisis (this could include severe depression, suicidal thoughts or attempt to commit suicide, a psychotic episode or nervous breakdown)

Yes

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(If yes, please describe in detail below):

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Are you currently in therapy or involved in any form of support group or practice:

Yes

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(If yes, please describe what kind and for how long below):

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Are you currently taking any form of medication:

I am not currently taking any medications

Yes, I am currently taking medications

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If yes, please give names, dosage and reason for taking it:

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Is there anything else about your physical or emotional status we should be aware of:

Yes

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Please describe if you chose YES

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Have you ever purposely injured yourself or somebody else:

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From a scale going from 1 to 10 (1= being in very poor health and 10= very good health), could you indicate how you have been feeling in the last couple of months or weeks.

Emotionally:

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Physically:

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Please let us know any additional details that your feel are important to share:

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I understand that this Blue Magic Alchemy Breathwork workshop is intended as a personal growth experience and should be used as a substitute for psychotherapy.

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I understand that Blue Magic Alchemy Breathwork could involve dramatic experiences accompanied by strong emotional and physical release.

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In order to get the benefits of this workshop and to be safely grounded and ready to return home, all of the various pieces of the workshop (intro talk, sitting, mandala drawing, group sharing, end of day integration talk) are very important. Because of this and also because I may have an expanded state of awareness experience, I understand that in order to be accepted to attend this workshop, I AGREE TO STAY FOR ENTIRE EVENT. If, despite the above, I still decide to lear the workshop without completing it, I UNDERSTAND AND AGREE that (1) I will notify a Facilitator before leaving to receive and of the Facilitator's instructions/directions which could minimize the consequences of early departure; and (2) in accordance with "Release, Waiver, and Indemnity of Liability Agreement", I will be accepting full responsibility for any consequences of leaving early and release and waive any and all claims which I might have against Blue Magic Alchemy LLC in connection with my early departure.

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I do hereby confirm that I have read and understood the above information and answered all questions completely and honestly, and have not withheld any information. If there are any changes in regards to the answers above between now and the time of the workshop, I will notify Blue Magic Alchemy, LLC in writing immediately. My general health, as far as I am aware, is good.

Confirm

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Medical Confirmation and Release

Any "Yes" answers must be explained in detail.

Registration