Empower Breathing Pattern Assessment Form

Empower Breathing Questionnaire
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Today's Date

MonthDayYear
This information will be kept strictly confidential as per the Health Professions Act, Personl Information Protection Act, the requlations of each of the professional governing bodies for the professionals at Empower Health and Canadian law. Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.

Select from the following

	Never	Rare	Sometimes	Often	Very Often
I get easily Breathless out of proportion to my fitness
I am breathless even when resting
I notice myself breathing shallowly
I get short of breath reading or talking out loud
I have trouble coordinating my breathing when I speak
I often cannot take a deep and satisfying breath (I.e. I can’t breath in or out all the way)
I notice I am breathing irregularly
My breathing feels stuck or restricted
I notice myself breathing quickly
I find myself holding my breath
I can’t catch my breath
My breathing requires work or effort
I breath through my mouth during the day
I breath through my mouth while sleeping
I have problems focusing and concentrating
I notice myself yawning
I notice myself sighing
I have tight feelings around my mouth
I have cold hands or feet
I have a tight feeling in chest
I have sleep apnoea
I have tingling fingers
I feel fatigued
I have sleep problems
I’m waking up tired
I have heart palpitations (i.e. I can feel my heart beating)
I have a Hernia
I have an ulcer or cyst in my abdomen
I have epilepsy
I grind my teeth at night
I clench my jaw
I feel tension in my jaw joint

Empower Breathing Questionnaire