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PERSONAL DETAILS: Mr. Mrs. Ms. Miss. (Please circle) (City of Oakland)

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CLIENT INFORMATION
PERSONAL DETAILS: Mr. Mrs. Ms. Miss. (Please circle)
FIRST NAME: _______________________________ SURNAME: _________________________________________________
Parent’s name if under 18: _______________________________________________________________________________
ADDRESS: _______________________________________________________________________________________________
_____________________________________________________________________________ POST CODE: ______________
TELEPHONE: (HOME)_______________________ (WORK)______________________(MOBILE)_______________________
EMAIL (please print clearly): _____________________________________________________________________________
(For appointment remi
nders, news, notification of publications and courses)
AGE: _____ DATE OF BIRTH: _______________ OCCUPATION: ________________________________________________
MALE/FEMALE: __________ HEIGHT: ____________ WEIGHT: _______________
REFERRED BY: _____________________________________________________________________________________________
GP: ____________________________________________ SPECIALIST DOCTOR: _____________________________________
I give consent for a report to be sent to my doctor/health practitioner: YES NO
Where did you hear about our clinic? ______________________________________________________________________
Important
I understand that this is a course of health education which includes breathing exercises and lifestyle guidelines. I
acknowledge that breathing education does not diagnose illness, disease or mental disorder and does not
prescribe medical treatment of pharmaceuticals. I understand that breathing training does not take the place
of medical diagnosis and treatment and that it is recommended that I see a medical doctor for any physical or
mental illness that I might have.
I agree that I have stated all medical conditions, treatments, medications or information required to complete an
informed breathing training session or program and I will keep the practitioner updated regarding any changes
to information prior to future sessions. I therefore declare that all the information supplied is true and correct to
the best of my knowledge. This information will remain private and confidential unless written or verbal
authorisation is given to send a report/letter to a doctor or other health practitioner.
I understand that the method taught to me is tailored to suit me and that completion of this course does not
qualify me to teach the Buteyko Institute Method. I agree not to give my course material to others.
CLIENT SIGNATURE ……………………………………………………………………....… DATE…………………………………….
(If under 18 years of age, this form must be signed by a parent or guardian)
Name: _______________________________________ 2
Medical Background
Ever
had?
(
P
)
Condition
From what age?
Recurring, intermittent,
ongoing?
Present severity
0 = not present now; 1 = mild;
2 = moderate; 3 = severe
Are you
having
treatment? (
P
)
Allergies (specify)
Anaemia
Asthma
Autoimmune disease (specify)
Anxiety/panic attacks
Bronchiectasis
Chronic fatigue syndrome
Cancer
Cystic Fibrosis
Chron’s disease
Depression
Diabetes
Emphysema/COPD
Epilepsy
Heart condition (specify)
High blood pressure
Low blood pressure
Kidney disease (specify)
Hypoglycaemia
Migraine headaches
Multiple sclerosis
Schizophrenia or bipolar
Irritable Bowel syndrome
Sleep apnoea
Other (please specify)
What is your most severe health problem? __________
__________________ Regularity of episodes: _____________
Date of most recent hospitalisation: ____________ Reason: ________________________________________________
Other hospitalisations: ___________________________________________________________________________________
Do you have a family history of: Hay fever: Allergies: Asthma: Epilepsy:
Are you prone to colds, flu, sinus or chest infections? ______________________________ Colds per year:__________
How many times have you used antibiotics in the last two years? ___________________________________________
Have you ever smoked? Y / N ______ Do you currently smoke? Y / N ______ How many per day ___________
If you are female are you pregnant? Y / N
3
Name: _______________________________________
Dental History
Have you had any dental extractions or surgery? (specify): _________________________________________________
Have you ever had a dental appliance or braces? (specify): _______________________________________________
Have you had: Tonsils removed? Adenoids removed? Root canal therapy?
Mercury amalgam fillings (number): ________ Do you have temporomandibular joint (TMJ) problems?
Sleep Disordered Breathing - Treatments and Appliances
Snoring Frequency: Loudness: (1=very quiet, 10 = very loud): _______
Have you had apnoeas, choking or gasping in your sleep? Sleep per night (average): ______
hours Have you had a sleep study? Date: _____________________ Copy or report attached
Treatments/appliances
Tried it
yes/no
Currently using?
From (date)
Successful?
CPAP machine
Dental splint
Surgery to palate/uvula
Nasal/sinus surgery
Epworth
Sleep Questionnaire
Use the following scale to choose the most appropriate number for the situation:
0 = would never doze, 1= slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance of dozing
Situation
Number
Situation
Number
Sitting and reading
Watching television:
Sitting, inactive, in a public place (theatre, meeting,
etc
As a passenger in a car for an hour without
a break
Lying down to rest in the afternoon when
circumstances permit
Sitting and talking to someone
In a car, while stopped for a few minutes in traffic
Sitting quietly after lunch without alcohol
Driving a car or truck for two (2) hours or more
Total:
Current Medication (Please record all medication and supplements currently being used)
Medication (name)
Strength
(mcg or
µg)
Assessment 1
Date:________________
Dose am / Dose pm
Assessment 2
Date:________________
Dose am / Dose pm
Assessment 3
Date:________________
Dose am / Dose pm
Assessment 4
Date:_______________
Dose am / Dose pm
0
4
usually
Eating Habits
Do you aim for healthy nutrition? never rarely occasionally
Are you mindful of your sensation of satiety?
Drinks How many caffeinated drinks (coffee/tea/coke) do you have a day?
How many alcoholic drinks do you have a week? (250mls beer or 1 small glass of wine = 1 standard drink)
Exercise/Sedentary Behaviour
How much time do you usually spend doing physical activity in a typical week? (list all moderate and vigorous
sports, fitness, leisure and/or work activities)
Activity
Intensity
Frequency and Duration
(eg walking)
moderate
40 minute walks x 3
The fo
llowing question is about sitting or reclining at work, at home, getting to and from places, or with friends
including time spent sitting at a desk, sitting with friends, traveling in car, bus, train, reading, playing cards or
watching television, but do not include time spent sleeping.
How much time do you spend sitting or reclining on a typical day? _________________________________
Time
Day 1
Time
Day 2
Breakfast
Lunch
Dinner
Snacks
I realise when I become sated and stop eating
I realise when I become sated but continue eating
I rarely realise when I become sated and often eat too much
none/less than one cup 1-2 cups 3-4 cups 5-6 cups more than 6 cups
none 1-3 4-5 6-7 8-12 more than 12
Name: ___
____________________________________
Diet
Please list your food intake for two specific days over the last week, preferably including 1 week and 1
weekend day. In case your eating habits during the previous week have differed significantly from your
habitual routine (due to being on holiday, sick etc.), please regard the time before this period:
Name: _______________________________________ 5
Symptoms Questionnaire
The signs and symptoms listed below have been associated with breathing dysfunction.
Please circle or highlight each individual sign or symptom that you experience at least once a week, or which
are significant at certain times of the year. It is not uncommon to have 15 or more different signs or symptoms.
Respiratory and Sleep-Related
Upper chest breathing
Fast/erratic/heavy breathing at rest
Excessive mucus/congestion (nose, sinuses) (day)
Excessive mucus/congestion (nose, sinuses) (night)
Excessive mucus/congestion (lungs) (day)
Excessive mucus/congestion (lungs) (night)
Runny nose - tissues used (day _____) (night ____)
Post nasal drip
Chest tightness
Wheezing
Short of breath at rest
Short of breath on exertion
Coughing (other than with infection)
Loss of sense of smell
Hay fever, sneezing
Yawning or sighing
Dry mouth (day)
Frequent deep breaths
Frequent need to clear throat
Mouth-breathing (day at rest)
Mouth-breathing (activity and mild exercise)
Mouth-breathing (sleep)
Nasal polyps
Enlarged/inflamed adenoids
Swollen tonsils
Prone to colds
Audible breathing during sleep
Snoring
Number of wakings per night _____
Number of toilet visits per night _____
Frequent or urgent urination (day)
Wake self with gasp/snort/choke
(times per night _____ per week _____)
Breathing stoppages in sleep noticed by others
Grinding teeth
Insomnia
Frightening/intense dreams
Restless legs
Bedwetting
Waking up tired
Dry mouth (on waking)
Bad breath (on waking)
Headache (on waking)
Nasal/sinus congestion (on waking)
Sleepiness during the day/wanting a nap
Falling asleep sitting, reading, watching TV, driving
Musculoskeletal
Muscle tension, spasms or cramping
Muscle tremors, twitching or tics
Muscle pain, weakness
Circulatory/Cardiovascular
Irregular, pounding, or racing heart
Chest pains that are not heart related
Flushing
Cold hands or feet
Nervous System/Psychological
Anxiety, tension, apprehension
Feeling revved up, jumpy, irritable
Feeling down
Panic attacks
Disturbance of consciousness
Poor concentration/memory or confusion
Fear without reason, fear of sultry air
Feelings of unreality or "losing the mind"
Generalised weakness or "weak at the knees"
Feeling light-headed, dizzy, unsteady or faint
Numbness or tingling of hands, feet, limbs, face
Headache (day)
Migraine
Epileptic seizures
Digestion
Abdominal bloating
Belching, flatulence
Heartburn, reflux
Difficulty swallowing
Irritable bowel
General
Easily tired, exercise intolerant
Chronic exhaustion
Weight gain/loss
Excessive sweating or clamminess
Allergies - food
Allergies - pollen, dust, mould etc.
Chemical sensitivities
Dry, itchy or inflamed skin
Red or itchy eyes
Dry lips
Increased thirst
Ringing, buzzing or hissing in ears
OTHER SYMPTOMS YOU MAY EXPERIENCE
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
Please describe in a few sentences what you hope to gain from improving your breathing?
Name: _______________________________________ 6
Breathing Symptoms Tracker
Please fill in the first 3 columns (highlighted in bold) below. This does take some time but is an important part of
your breathing assessment and if possible we try to avoid using valuable time in the consultation doing this.
Assessment 1 takes place before your breathing assessment. Assessments 2 and 3 take place during the course
and assessment 4 takes place 6 weeks after the course. These regular assessments allow you to assess and monitor
your progress.
Symptom
(Please write ALL the symptoms you
circled on the previous page 5 into
this column)
Rate Frequency
Daily
Weekly
Monthly
Seasonally
Rate Severity - Rate 1 to 4
1 = mild, 2 = moderate, 3 = moderate to severe,
4 = severe (Leave box empty if symptom has resolved)
Assessment 1
(Pre-course)
Date:
Assessment 2
(Session 4)
Date:
Assessment 3
(Session 5)
Date:
Assessment 4
(6 week f/-)
Date:
TOTAL SYMPTOM SCORE
0
0
0
0
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PERSONAL DETAILS: Mr. Mrs. Ms. Miss. (Please circle) (City of Oakland)

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Completed 1 March 2021

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