Breathwork client intake form: a safety checklist template

How do you screen people before a breathwork class?

Here's a simple process, based on the research screening steps further down.

1. Send the form at least a few days before the first class. The 2025 study below sent its questionnaire a week ahead.
2. Read every form yourself. Don't skip a "yes" because the person seems fine.
3. For any yes, have a short, private chat. Don't diagnose. Suggest they check with their doctor.
4. Offer the gentle option to everyone: seated or lying, slow breathing, no breath holds, no fast or forced breathing, free to stop.
5. Ask "how are you today?" at the start of every class. The PAR-Q+ itself says its clearance lapses after 12 months or if a condition changes.
6. Keep the forms private and delete them when you no longer need them. Health information rules differ by country, so ask a lawyer.

Is there a standard breathwork safety checklist?

No. I searched for a published consensus, guideline or systematic review on screening people for breathwork and found none. What exists are provider forms and waivers.

What we do have is how researchers screen people, and that is a useful starting point.

What breathing trials screened out. The cyclic sighing trial excluded people with self-reported moderate-to-severe psychiatric or medical conditions that taking part could worsen. It named heart disease, glaucoma, seizure history, pregnancy, psychosis, suicidality, bipolar disorder and substance use disorders, citing health and safety reasons (Balban et al. 2023).

A 2025 study of intense circular breathwork in 61 experienced practitioners excluded psychosis, personality disorders, recent substance use disorder, cardiovascular disease (such as poorly treated high blood pressure or arrhythmia), chronic lung disease (such as asthma or COPD), pregnancy and epilepsy. It also used a questionnaire a week ahead, a phone check-in, and a short medical exam on the day. Heart rate over 100 or blood pressure over 160 meant exclusion (Havenith et al. 2025).

That's research-level screening, and a community class can't match it. It's a good reason to keep your classes gentle.

Why screen at all? Breathing faster or deeper than normal can cause lightheadedness, chest pain, a racing heart, tingling around the mouth or in the arms, and muscle spasms. Cleveland Clinic says to get medical care right away for rapid breathing for the first time (Cleveland Clinic). A meta-analysis of breathwork trials found no adverse events attributed to breathwork, but asked for more consistent reporting, especially for fast-paced styles (Fincham et al. 2023). No reports isn't proof of safety.

Epilepsy, specifically. Among 433 people with confirmed epilepsy who hyperventilated for 5 minutes during an EEG, 2 (0.46%) had a seizure (Holmes et al. 2004, abstract only). That's a rare outcome under clinical supervision, not a safety guarantee for a class.

An existing tool, with a catch. The PAR-Q+ asks seven general health questions about heart condition or high blood pressure, chest pain, dizziness or fainting, other chronic conditions, medications, bone or joint problems, and medically supervised activity. It says to delay activity when pregnant or ill and consult a professional. But it tells people to answer NO to the dizziness question if dizziness came from over-breathing (PAR-Q+ 2025). For breathwork that exception doesn't make sense, so the template below reverses it. The PAR-Q+ is copyrighted, so I paraphrase its topics and don't reproduce it.

The research in a nutshell

Weak. Screening lists rest on research-safety rules and general health pages, not on tests of what works.

The template: breathwork intake form (copy and adapt)

Template only. Not legal or medical advice. Have a clinician and a lawyer review it before use.

Part A: Details. Name, contact number, emergency contact, date, class name. If the participant is under 18, a parent or guardian must sign.

Part B: Health questions. Answer yes or no. Any yes means "talk to your doctor before joining" (and see the gentle option).

1. A doctor has told me I have a heart condition or high blood pressure.
2. I have chest pain at rest, in daily life or when active.
3. In the last 12 months I have lost balance because of dizziness, fainted, or lost consciousness. (Include dizziness from over-breathing.)
4. I have epilepsy, or have had a seizure.
5. I have asthma, COPD or another lung condition.
6. I am pregnant, or may be.
7. I have glaucoma or another serious eye condition.
8. I have a history of psychosis, bipolar disorder, thoughts of suicide, or a substance use disorder, or I am under care for a serious mental health condition.
9. I have another chronic medical condition, or take prescribed medication for one. (Please list.)
10. A doctor has told me to do only medically supervised activity.
11. I am ill today (for example a fever or cold), or feel unwell.

Part C: In-class agreement. - I can change my pace, breathe normally, open my eyes or stop at any time. - I will stop and tell the facilitator if I feel dizzy, faint, short of breath, tingly in my hands, arms or around my mouth, have chest pain, a racing heartbeat or muscle spasms. - I understand this class is not medical care and does not replace advice from my doctor.

Part D: Consent. "I have answered honestly. I understand I take part voluntarily and can stop at any time. I will tell the facilitator if my health changes." Name, signature, date.

Facilitator checks in class. Gentle default with no holds. If someone shows the signs in Part C, ask them to return to normal breathing and sit comfortably. For chest pain, or rapid breathing that starts for the first time, seek medical help.

Where does each question come from?