Workshop Registration BUTEYKO INTAKE FORMThe 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:*FirstLast Parent/Guardian name if client is under 18FirstLast Address:* Street Address City State / Province / Region Postal / Zip Code Telephone:* Area code - Telephone Email:* Date of Birth:* Occupation: If retired, former occupation: Have you had COVID?*No, not that I know ofYes, I was NOT hospitalized and am still suffering symptoms symptomsYes, I was NOT hospitalized and am free of residual symptomsYes, I was hospitalized and am free of residual symptomsYes, I was hospitalized and am still suffering symptoms symptoms If you had COVID what were your symptoms? If you had COVID and are still suffering symptoms, what are those? Reason for most recent hospitalization (except COVID): Your most severe health problem(s): Nasal surgery other than for sleep apnea?YesNo Have you had your tonsils removed?YesNoDo you have a family history of: Allergies?YesNo Asthma?YesNo Hay Fever?YesNoFemales only: Are you pregnant?YesNoHave you ever smoked?: Ever?YesNo Current?YesNo Date of hospitalization: Regularity of episodes: Reason? Reasons for other hospitalizations: Anti-depressants Blood Pressure Herbals and Supplements Antibiotics Diabetes Heart Other Medication + Purpose Single Choiceoption 1option 2 Medication Medication1 Medication2 Medication3 Medication4 Medication5 Medication6 Strength (all meds) Strength1 Strength2 Strength3 Strength4 Strength5 Strength6 AM - PM Doses Doses1 Doses2 Doses3 Doses4 Doses5 Doses6 Treatment / Appliance TA2 TA3 TA4 TA5 TA6 Sleep study done?YesNo Year? Recommended?YesNo Rec2YesNo Rec3YesNo Rec4YesNo Rec5YesNo Rec6YesNo Tried it?YesNo Tried2YesNo Tried3YesNo Tried4YesNo Tried5YesNo Tried6YesNo Using - Not (reason) Use2 Use3 Use4 Use5 Use6 Successful?YesNo Success2YesNo Success3YesNo Success4YesNo Success5YesNo Success6YesNo BracesYesNo Tooth Extraction?YesNo Jaw expansion surgeryYesNo Expander?YesNo Dental Implants?YesNo FrenectomyYesNo OMT?YesNo Root canals?YesNo Speech Therapy?YesNo Please comment on any of these treatments: Heart Condition (not previously mentioned)YesNo Severe renal failure (includes dialysis)YesNo AnginaYesNo High blood pressureYesNo Low blood pressureYesNo Diabetes (Type1)YesNo Diabetes (Type2)YesNo EpilepsyYesNo Fluid retentionYesNo Panic attacksYesNo Brain tumorYesNo Life threatening illnessYesNo Major surgeriesYesNo COPDYesNo History of severe cardiac rhythm disorderYesNo Uncontrolled hyperthyroidismYesNo SchizophreniaYesNo Current cancer treatmentYesNo Recent heart attackYesNo High cholesterolYesNo MigrainesYesNo Underactive thyroidYesNo Overactive thyroidYesNo Arterial aneurysmYesNo ScoliosisYesNo Illness? Surgeries? Type COPD? Blood Disease (not previously mentioned)YesNo Uncontrolled hypertensionYesNo Sickle cell diseaseYesNo Kidney diseaseYesNo Hemorrhagic strokeYesNo HypoglycemiaYesNo HyperventilationYesNo DepressionYesNo ThrombosisYesNo What to you hope to gain from improving your breathing? Name of Doctor: Name of Specialist: Referred by: Send Report to Doctor?Yes Send Report to Specialist?Yes By checking the box below you are digitally signing this form* I am not a robotSubmitReset
