Workshop Registration Form

PERSONAL DETAILS

BUTEYKO INTAKE FORM

The information on this form supplied to the educator by the client is entirely voluntary.
This document is completed with the understanding that it is the choice of the client to receive breathing training on this and return occasions.
You understand your breathing educator cannot prescribe a medical treatment or medications.
Breathing training does not take the place of medical treatment and when in doubt you should consult your doctor.

You agree you have stated all medical conditions, treatments, medications or information required to complete an informed breathing training session and you will keep the educator updated on any changes to information prior to future sessions.
You therefore declare that all information supplied will be true and correct to the best of your knowledge.
This information will remain private and confidential unless written authorization is given by the client to release file details, or when verbal consent is given to send a report/letter to a doctor or other health practitioner who has referred or recommended you to our program.

Date:
Name:*
Parent/Guardian if client is under 18
Address:*
Cell phone:
-
Home phone:
-
Work phone:
-
Date of Birth (mm/dd/yy)
Email:*
Occupation:
If retired, former occupation:
MEDICAL HISTORY
Reason for most recent hospitalization:
Your most severe health problem(s):
Nasal surgery other than for sleep apnea?
Have you had your tonsils removed?

Do you have a family history of:

Allergies?
Asthma?
Hay Fever?

Females:

Are you pregnant?

Have you ever smoked?:

Ever?
Current?
Date of hospitalization:
Regularity of episodes:
Reason?
Reasons for other hospitalizations:
CURRENT MEDICATIONS (except asthma / COPD)
Anti-depressants
Diabetes
Antibiotics
Other Medication + Purpose
Heart
Herbals and Supplements
Blood Pressure
ASTHMA / COPD MEDICATION AND DOSAGES
Medication
Strength (all meds)
AM - PM Doses
SLEEP DISORDERED BREATHING
Treatment / Appliance
Sleep study done?
Year?
Recommended?
Tried it?
Using - Not (reason)
Successful?
DENTAL / OTHER
Braces
Tooth Extraction?
Jaw expansion surgery
Expander?
Implants?
Frenectomy
OMT?
Root canals?
Speech Therapy?
Please comment on any of these treatments:
CHECK YOUR CURRENT CONDITIONS
Heart Condition (not previously mentioned)
Severe renal failure (includes dialysis)
Angina
High blood pressure
Low blood pressure
Diabetes (Type 1)
Diabetes (Type 2)
Epilepsy
Fluid retention
Panic attacks
Scoliosis

Life threatening illness
Major Surgeries
Chronic Obstructive Pulmonary Disease
History of severe cardiac rhythm disorder
Uncontrolled hyperthyroidism
Schizophrenia
Current cancer treatment
Recent heart attack
High cholesterol
Migraines
Underactive thyroid
Overactive thyroid
Arterial aneurysm
Thrombosis

Illness?
Surgeries?
Type COPD?
Blood Disease (not previously mentioned)
Uncontrolled hypertension
Brain tumor
Sickle cell disease
Kidney disease
Hemorrhagic stroke
Hypoglycemia
Hyperventilation
Depression
What to you hope to gain from improving your breathing?
Name of Doctor:
Name of Specialist:
Referred by:
Send Report to Doctor?
Send Report to Specialist?
By checking the box below you are digitally signing this form*
I am not a robot