Buteyko Student Questionnaire

Moving Breath Project
Kathleen Rea's Buteyko Classes

Student Name

First NameLast Name

Date questionnaire was completed:

Date

What gender do you identify as, and what are your pronouns?

What are your hopes or reasons for taking this Buteyko series?

Do you have occupations and/or special interests? If so, please briefly describe.

My occupations and/or special interests involve?

	None	Low amount	Medium amout	High amount	Very high amount
Physical Exercise
Talking

Physical Exercise you get on average per week?

	Less than an hour	1-2 hours	3-4 hours	5-6 hours	7 or more
On average each week I get this amount of physical exercise

What type of exercise do you do?

List any medical conditions (physical or mental) or symptoms that concern you. Please let me know 1) when these started and 2) level of 3) severity.

Generally, any symptoms or medical conditions I listed above:

	I know I have the condition, but I don't really notice it that much.	Only sometimes	Comes and goes episodically.	A few times a week	Occurs daily	Occurs all day long
Level of symptoms

Have you ever been admitted to the hospital for asthma attacks or other breathing issues in the past four years? If so, please give a description and frequency.

If you take Asthma medication, please list Preventer medication: TYPE, DOSE and NUMBER of times a day and your Reliever medication TYPE, DOSE and NUMBER of times a day you tend to use it.

Are you on medication for any other type of condition? If so, please list them and what they are for.

Self-assessment of the depth of your breathing

	low into my diaphragm	With a mix of deep and shallow depending on the circumstances	Shallow (high in upper chest with my shoulders moving with each breath)	Not sure
I tend to breathe

Self-assessment of mouth versus nasal breathing

	Never	Sometimes	Often	Very Often	Not sure
Is your nose blocked
DAY: Mouth breathing during the day?
WAKE-UP: dry mouth?
EXERCISE: Mouth breathing while exercising?
SLEEP: Mouth breathing while you sleep?

Breathing while sleeping

	Yes	No	Not sure	No applicable
Do you snore at night?
Do you think you have sleep apnea (bouts of not breathing while you sleep)
Have you been diagnosed with sleep apnea?
Have you ever been prescribed a C-PAP machine?
If so, do you currently use it?

Do you smoke or vape? If so, how often do you do so per day or week?

Have you ever been diagnosed with a lip or tongue tie? If so, have you had it released? If you have had it released, please let me know when.

How many glasses of water do you tend to drink per day?

Do you drink alcohol or take recreational drugs? If so, please describe type and amount per week.

Are you on any special diet? If so, please explain.

Have you ever eliminated or reduced dairy for your breathing?

YesNo

If you have eliminated or reduced dairy for your breathing, did it help?

YesNoSomewhatNA

Have you ever done Myofunctional Therapy (mouth, face and tongue exercises)? If so, please describe and let me know when.

Nijmegen's Chronic Hyperventilation Assessment:

	Never (0 points)	Rarely (1 point)	Sometimes (2 points)	Often (3 points)	Very often (4 points)
Chest wall pains
Feeling tense
Blurred vision
Dizzy spells
Confusion, losing contact with reality
Fast or deep breathing
Shortness of breath
Tightness in chest
Bloated feeling in stomach
Tingling fingers
Unable to breathe deeply
Stiffness in fingers or arms
Stiffness around mouth
Cold hands or feet
Thumping of your heart
Feeling Anxiety
ADD UP EACH COLUMN

Can you add up your TOTAL score for Nijmegen's Assessment? (Never 0)(Rarely 1) (Sometimes 3) (Often 4) (Very often 4). A score of over 23 to 64 suggest a positive diagnosis of chronic hyperventilation syndrome.

Kathleen's Chronic hyperventilation and disordered breathing assessment:

	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
Coughing
Wheezing
Asthma
Exercise induced Asthma
Breathlessness at rest
Breathlessness with exercise
Frequent yawning
Frequent sighing
Fast breathing
Needing to breathe halfway through a sentence
Blocked nose
Insomnia
Waking up at night to pee
Notice or told that you stop breathing at night
Nightmares
Bed wetting at night
Frequent waking at night
Waking up because of a gasp
Waking up with dry mouth
Headache upon waking
Headaches durring the day
Trouble remembering things
Poor coordination
Tiredness or exhaustion
Worrying or apprehension
High stress
Panic attacks
Depression
Stomach upset
Achy muscles
Sore muscles after a work-out
Feeling weakness in muscles
Excessive sweating
Sweaty palms
Tight chest feeling
Racing heart
Lightheaded or dizzy
Heart pounding
Skipping or irregular heart beat
Vertigo
Frequent cold hands
Constipation
Excessive need to pee
Frequest colds
High blood pressure
Irritable Bowle Symptoms (IBS)
Frequently or easily break your bones
ADD UP EACH COLUMN

Can you add up your TOTAL score for Kathleen's Assessment? (Never 0)(Rarely 1) (Sometimes 3) (Often 4) (Very often 4). A score of over 70 to 184 suggest a positive diagnosis of hyperventilation syndrome or another type of breathing disorder.

Do you have any concerns about taking this Buteyko course?

Please indicate if you have any accessibility questions or access accommodations that will help you feel comfortable in this course and/or help you benefit from the course.

Pregnancy: Please tell the practitioner if you are currently pregnant and if so at what stage of pregnancy you are.

INFORMED CONSENT: Kathleen graduated as a teacher of the Buteyko Method in 2022 through training with Patrick McKeown. In Kathleen's Buteyko series she teaches and describes: 1) Mouth-taping 2) Breathing exercises that teach participants to breathe Light (low volume with ease), Slow, and Deeply (with diaphragm) 3) Breathing exercises that expose you to tolerable air hunger (air hunger is a feeling of needing the breathe more air) 4) Strategize how to condition the nose to enable a shift to predominantly nose breathing and 5) Movement, alignment, and strengthening exercises that work to strengthen the deep-front-line with the aim to improve tongue strength and oral posture. All participants are led to do these exercises at their own pace and within a reasonable comfort level. The Moving Breath Project does not diagnose, treat, or cure any disease or condition. No claims are made by the Moving Breath Project as to specific health benefits that will result from taking our workshops. Please refer to this page on the Buteyko website to see studies that indicate possible effects the Buteyko Method may have (https://buteykoclinic.com/buteyko-trials/). Individuals should consult a qualified health care provider for medical advice if they feel the need prior to participation, or if Kathleen requests. Participants assume all responsibility and risk for the use of the information taught in our workshops. Also please note, participants will often need to put in significant and ongoing hours of work to see the most effects. Those that find a way to incorporate the Buteyko Method as part of their daily living are often the ones that see the most positive effects.

	YES
I HAVE READ THE INFORMED CONSENT

AGREEMENT: I agree to seek medical consult prior to starting the workshop should Kathleen ask me to. I agree not to decrease or alter my medications without prior consultation and approval from a Medical Doctor even if my symptoms abate or disappear. I confirm that I have read and fully understand that failing to comply with this direction may pose a risk to my health and that it would be against the recommendations of Kathleen Rea. I have been informed of the nature of the course and agree to participate.

	YES
I AGREE WITH THE ABOVE STATEMENT

How did you hear about this course:*

	YES	NO
Social media
Friend
Newspaper
GP or healthcare consultant
Internet search
Radio
Moving Breath Project Website

STUDENT SURVEY

The following two sets standardized questionnaires to evaluate possibility of chronic hyperventilation syndrome (low level of taking in more air then you need) and/or other breathing disordered.