Microsoft word - buteyko class health intake form

LISA BOWEN/BREATHING RETRAINING CENTER
HEALTH INTAKE FORM

PLEASE FILL IN ALL THE INFORMATION ON EACH OF THE FOUR PAGES RELEVANT TO YOU:
Name: Mr / Mrs / Ms / Miss ___________________________________________________________
Address:
______________________________________________________________________ ______________________________________________________________________ Email address: _____________________________________________________________________ Telephone: Home:__________________Work __________________Mobile:___________________ Current Occupation:_______________________ Past Occupations:____________________________ MEDICAL HISTORY
Type of Illness: (e.g. Asthma, panic attacks, sleep apnea) ___________________________________
Degree: (e.g. Mild, Moderate, Severe)
Regularity of attacks or problems (daily, weekly, monthly) ___________________________________ Age originally diagnosed: ______________ Date of birth: __________________ Age now: _________ Current
Medical Practitioner: ______________ _____________________ Telephone: ___________________
Last time hospitalized for asthma: _________________
Date you last took cortisone orally or by injection (e.g. Prednisone, Prednisolone, Methylprednisone):
_______________________
Have you ever suffered from the following problems?:
Current? Current?
Current?
Females, are you pregnant? YES ___ NO ___ Please list other symptoms on Page 3
Have you had any major surgeries?
Have you had any life threatening illnesses? Drugs are you allergic to _________________________________________________ _______________________________________________________________ What things besides drugs are you allergic to? _______________________________ Lisa Bowen/Breathing Retraining Center  www.breathingretrainingcenter.com/info@breathingretrainingcenter.com 415-454-3400 LISA BOWEN/BREATHING RETRAINING CENTER
HEALTH INTAKE FORM

COMPLETE THIS PAGE IF YOU HAVE ASTHMA, COPD
NAME: _________________________

Please list all drugs you are currently taking, or have taken, in the past two months whether related
to breathing difficulties or not.

"Inhaler" Medication:
Albuterol
Combivent
Atrovent
Proventil
Ventolin

Slow Release Relievers:
Theophylline
Serevent
Symbicort

Preventers:
Inhaled
Tablet
Azmacort
Prednisone
Singulair
Combined drugs:
Pulmicort
Symbicort
Vanceril

Nebulizer Use:
Albuterol
Atrovent
Ventolin

Nasal Spray Use:
Rhinocort
Nasocort
Lisa Bowen/Breathing Retraining Center  www.breathingretrainingcenter.com/info@breathingretrainingcenter.com 415-454-3400 LISA BOWEN/BREATHING RETRAINING CENTER
HEALTH INTAKE FORM
COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
OTHER MEDICATION NOT RELATED TO ASTHMA:

Medication
Condition
Comments

Do you or did you ever smoke? YES ___ YES, have stopped ___ NO ___ If yes, how long? ____
If yes, how many packs per day?_____ If stopped, when did you stop smoking?___________
Please explain any surgeries:
____________________________________________________________________________ ____________________________________________________________________________
If you checked a life-threatening illness:

Sleep apnea/ snoring
If you checked major surgeries:
Do you have a blood disorder?
YES ___ NO ___ If yes, which? ________________________ Have you been diagnosed with any chronic condition? YES ___ NO ___ If yes, which? __________
Are you experiencing chronic pain?
_______________________________________________________________________________________ Lisa Bowen/Breathing Retraining Center  www.breathingretrainingcenter.com/info@breathingretrainingcenter.com 415-454-3400 LISA BOWEN/BREATHING RETRAINING CENTER
HEALTH INTAKE FORM
COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
SYMPTOMS SUFFERED PRIOR TO COMMENCING COURSE Please check your symptoms:
Please list other symptoms __________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
I understand that the Buteyko Breathing Retraining Program is a series of lectures and training. It does
not constitute medical treatment. Furthermore, I, the undersigned, agree to only modify prescribed
medication after consultation with a medical doctor.
Name: ___________________________________. Date: _________________
Signed: ______________________________________________
If client is under 18, a parent or guardian must sign this form

Please tell me about why you are attending the course and what you hope to gain from it:
__________________________________________________________________________________
_________________________________________________________________________________
Lisa Bowen/Breathing Retraining Center  www.breathingretrainingcenter.com/info@breathingretrainingcenter.com 415-454-3400

Source: http://www.breathingretrainingcenter.com/resources/Buteyko%20Class%20Health%20Intake%20Form.pdf