Buteyko client intake form – Dru Yoga Cape Town and Buteyko Instruction

Name

First

Last

Email

phone no

Does your occupation require much TALKING or PHYSICAL EXERCISE?

Yes

No

What condition / symptoms do you have?

What year approx. were you first diagnosed with your condition?

Please state which best describes your condition:

Are you stressed during the day?

Do you experience cold hands or feet?

Do you notice yourself yawning regularly during the day?

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

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?

Yes

No

Have you completed a Sleep Study?

Yes

No

If yes, give approximate date:

Have you been prescribed a CPAP machine?

Yes

No

Do you currently use it?

Yes

No

Do you limit your intake of dairy foods?

Yes

No

How many hours a week do you partake in physical exercise?

Please indicate the level of severity of any of the symptoms that you experience in list below: 1 = Mild, 2 = Moderate, 3 = Severe

Breathlessness at rest

Exercise Induced Asthma

Coughing

Wheezing

Frequent Colds

Frequent Sighing

Sleep Apnoea

Frequent Yawning

Snoring

Tiredness

Insomnia /Broken Sleep

High Perceived Stress

Poor Concentration

Anxiety

Panic Attacks

Headaches

Achy Muscles

Tummy upset / IBS

Lower back pain

Excessive sweating

Nijmegen Questionnaire

Please indicate √ the level of severity of any of the symptoms that you experience in list below:

Feeling Tense

Blurred vision

Chest Wall Pains

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

Cold hands or feet

Thumping of the heart

Feeling of anxiety

Please indicate any other common symptoms that you may experience

Please list Asthma medications you take

Preventer

Daily does

Reliever

Daily does

Any other Medication

Please indicate if you have any concerns

By submitting this form
I understand that Sandy Mitchell is not a registered medical practitioner. 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/consultation 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 Sandy Mitchell 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 Sandy Mitchell, I understand and agree to do so at my sole risk.
I understand I will need to inform Sandy Mitchell 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 Buteyko Method exercises immediately and inform Sandy Mitchell 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 Sandy Mitchell 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.