Buteyko Screen - Floss Bosses

Please complete the questions below as accurately as possible so that your Course Instructor can assist you with your individual
Name
Contact Number
Please enter a valid phone number.
Parent's name (if applicable)
Email address
example@example.com
Occupation :
it require much TALKING or PHYSICAL EXERCISE? (Circle)
What condition/symptoms do you have?
1)
2)
When were you first diagnosed with your condition? (years)
Please state which best describes your condition:

Sometimes have symptoms:Continuous symptoms (mild):Continuous Symptoms (moderate):Continuous symptoms (severe):
How often have you been admitted to hospital for asthma attacks/or other, in the past three years ?
Do you feel that deep breathing is good for you?

YesNo
Do you feel stressed, anxious regarding your condition?

NeverSometimesOftenVery Often
Does your nose feel congested?

NeverSometimesOftenVery Often
Do you breathe through your mouth during the day?

NeverSometimesOftenVery Often
Do you breathe through your mouth during the night? (Do you wake up with a dry mouth?)

NeverSometimesOftenVery Often
Have you completed a Sleep Study?

YesNo
If yes, give approximate date

MonthDayYear
Date
Have you been prescribed a CPAP machine?

YesNo
Do you currently use it?

YesNo
Do you Smoke?

YesNo
IF yes, how many cigarettes a day
Do you limit your intake of dairy foods?

YesNo
Has this helped you?

YesNo
Approximately how many hours per week do you partake in physical exercise?

Less than one hour1-2 hours2-3 hours3-4 hours4-5 hours5-6 hours6-7 hours7 or more
Please indicate the level of severity of any of the symptoms that you experience in list below:
Coughing

MildModerateSevere
Wheezing

MildModerateSevere
Exercise Induced Asthma

MildModerateSevere
Frequent Colds

MildModerateSevere
Breathlessness at rest

MildModerateSevere
Frequent Sighs

MildModerateSevere
Frequent Yawning

MildModerateSevere
Sleep Apnoea

MildModerateSevere
Snoring

MildModerateSevere
Lower back pain

MildModerateSevere
Excessive sweating

MildModerateSevere
High Perceived Stress

MildModerateSevere
Tummy upset / IBS

MildModerateSevere
Achy Muscles

MildModerateSevere
Tiredness

MildModerateSevere
Insomnia/Broken Sleep

MildModerateSevere
Poor Concentration

MildModerateSevere
Panic Attacks

MildModerateSevere
Headaches

MildModerateSevere
Nijmegen Questionnaire: Please indicate the level of severity of any of the symptoms that you experience in list below:

Complaints

	Never	Rarely	Sometimes	Often	Verry Often
Chest Wall Pains
Feeling Tense
Blurred Vision
Dizzy Spells
Confusion, losing contact with reality
Fast or deep breathing
Shortness of breath
Tightness in the chest
Bloated Feelings in Stomach
Tingling of fingers
Unable to Breathe Deeply
Stiffness in fingers or arms
Stiffness around the mouth
Cold hands or feet
Thumping of the heart
Feeling of anxiety

Total Never
Total Rarely
Total Sometimes
Often
Verry Often
If you take asthma medication, please list:
Preventer
Daily Dose
Reliever
Daily Dose
What would you like to achieve from attending Buteyko Clinic?
How did you hear about this course:

Social MediaFriendNewspaperGP or ConsultantInternet SearchRadioHealth Care PractitionerOther
For Female participants: Please tell the instructor if you are currently pregnant.
DISCLAIMER
Please read the following disclaimer carefully before signing, and/or seek professional legal advice if necessary.

I understand that the Course Instructor is not a registered medical practitioner nor is anyone else at (company or business name). No advice and activity presented, demonstrated or advised during the Course are in any way intended as a substitute for a medical consultation, and should not replace or interfere with any guidance offered by a medical professional.

I understand that I am free to leave the Course at any time for any reason. If at any time during the Course, I feel the need for any assistance, medical or otherwise, I agree to notify my Course Instructor immediately and take full responsibility for the same, including leaving the course and obtaining appropriate care. If I fail to seek the required medical care or ignore medical advice, including that from my Course Instructor, I understand and agree to do so at my sole risk.

I understand I will need to inform my Course Instructor about my pregnancy status, if any, before starting the Course's training and exercises. If I become pregnant or believe I may be pregnant after starting the Course, I agree to stop all technique exercises immediately and inform my Course Instructor to guide me on the next course of action.

I hereby confirm that I have carefully read this disclaimer and have fully understood that this is a release of liability. I hereby expressly agree to release and discharge my Course Instructor, and/or anybody associated with (Company name (including its employees, directors, and/or management) from any and all claims or causes of action and agree to waive any right that I may otherwise have to bring a legal action against the said individuals for personal injury and/or damage to property.
Full Name of Participant
Signature

Clear
Date

MonthDayYear
Date
Full Name of Guardian
Signature

Clear
Date

MonthDayYear
Date
[N.B: Parent / Guardian's signature is mandatory if the participant is below 18 years of age]
Should be Empty:

DISCLAIMER