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Ice Bath Health Declaration

A short health form so we can hold the experience safely — one step at a time.

Step 1 of 5 20%

1) Declaration

I, the undersigned, declare that I have read and understood the nature of the breathwork and cold-exposure workshop, and that it includes rapid breathing, short breath holds on land, and optional cold-water exposure.

I declare that I have provided the instructor with all important medical information, including medications, pregnancy or possible pregnancy, heart, blood-pressure, lung and neurological conditions, fainting, epilepsy, Raynaud’s, recent surgeries, or any condition that may affect my safety.

I commit not to practice breath holds in or near water, to follow the instructor’s guidance, and to stop immediately if chest pain, unusual shortness of breath, confusion, sudden weakness, severe numbness, strong dizziness, or any unsafe feeling appears.

I understand that my participation is voluntary, and that I may decline any part or leave at any time without needing to explain. I also understand that the workshop is not a medical diagnosis or treatment.

2) Personal details

3) Ice bath health screening (1–7)

Chapter 12: Ice bath health screening questions

1. Do you have heart disease, arrhythmia, chest pain, catheterization, heart surgery, or a previous clot?

2. Do you have uncontrolled high or low blood pressure?

3. Have you ever fainted, especially during exercise, breathing, heat, or cold?

4. Do you have epilepsy, seizures, stroke, aneurysm, or a neurological injury?

5. Do you have uncontrolled asthma, lung disease, shortness of breath, or a recent respiratory attack?

6. Do you have Raynaud’s, poor circulation, neuropathy, or reduced sensation in the extremities?

7. Are you pregnant, possibly pregnant, or in the early postpartum period?

4) Ice bath health screening (8–14)

Chapter 12: Ice bath health screening questions

8. Do you have diabetes, kidney disease, a thyroid disorder, or a problem regulating body temperature?

9. Have you had recent surgery, or do you have an open wound, infection, fever, or an acute illness?

10. Do you take medication that affects the heart, blood pressure, alertness, clotting, or temperature regulation?

11. Have you consumed alcohol or a sedative in the last few hours?

12. Do you have a history of severe panic attacks, psychological trauma, or a difficult past experience with water/choking?

13. Have you slept, eaten, and drunk water appropriately today?

14. Is there any reason that makes you unsure about the safety of participating?

5) Signature

✓

Health form submitted

Thank you. Your declaration has been saved and we will contact you if needed.