Pre-Session Questionnaire

Thank you for choosing to explore Breathwork with us. Please take a few minutes to complete this confidential questionnaire. Your responses provide us with important context to tailor the session to your needs.

We value your privacy, and all information will be kept strictly confidential.

If you have any questions, feel free to contact us at exhale@breathewithsamreen.com.

Name

First Name

Last Name

Date of birth

YYYY

Understanding your birth experience helps us explore potential imprints on your breath patterns and emotional well-being, supporting a more tailored and effective session. What best describes your birth?

Natural labour

C-section

Don't know

Have you been diagnosed with any psychological conditions, or do you experience depression, anxiety? Please describe:

Do you take any medication? Please list and describe what it is for.

Are you pregnant? If so, what trimester?

Do you generally express emotions freely?

Yes

Not sure

Spirituality (Do you have any spiritual or religious practices? Do you meditate, or engage in activities that nurture your connection to your heart and soul?) Please describe:

To what extent do the following issues affect you today? To the best of your ability, please kindly answer these as accurately as possible. I smoke / vape.

I drink alcohol.

I over/under eat.

I use recreational drugs.

I experience extreme fatigue and exhaustion.

I suffer from headaches and/or migraines.

I suffer from digestive issues.

I experience pain.

I suffer from insomnia/sleeplessness.

I experience anxiety.

I feel anger.

I tend to feel isolated.

I feel depressed.

I have disproportionate reactions.

The quality of connection you experience. How connected do you feel with yourself?

How connected do you feel with your family?

How connected do you feel socially?

How connected do you feel professionally?

Please share anything else that would help us support you best:

Photography / Videography

Photos may be taken during the event for promotional or educational purposes. If you prefer not to be included, please check the box below. Rest assured, we will always seek your permission before sharing any content featuring you publicly.

I do not want to be included in promotional material.

I consent to being included in promotional material.

We are committed to protecting your personal information and processing it lawfully and transparently. Please see our Privacy Policy for more details. If you have any queries about this form or wish to update your personal details please contact us at exhale@breathewithsamreen.com.

Yes, please add me to your mailing list! I’d love to receive resources to support my breathing journey.

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