Breathe Naturally
Breathing retraining
Patient Referral Form
Referral Guidelines
Please fill out the referral form and fax to either the North or South location:
North: Calgary Winter Club Physiotherapy
4611 14 St NW
Calgary, AB T2K 1J7
403-289-0040 (ph)
403-289-9042 (fax)
South: Running Injury Clinic
Glenmore Landing
A201, 1600 – 90 Ave SW
Calgary, AB T2V 5A8
403-460-5642 (ph)
403-460-5646 (fax)
Alternatively, you may fill it out on-line and email to breathenaturallytoday@gmail.com Our office will contact the patient
to book an appointment. You may give a copy of the referral form to the patient as it has more information on the back.
For additional information, please visit www.breathenaturally.ca
Patient Information
Patient Name:
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Date of Birth:
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Address
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AHC #:
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Home Phone:
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Alt. Phone:
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Referral Information
Relevant Medical History: Click here to enter text.
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Medications:
Reason for referral:
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Referring Physician Information
Physician Name:
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Phone:
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Fax Number:
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Copy sent to:
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It is estimated that one in ten people experience dysfunctional breathing at some point in their lives,
and that up to one third of people diagnosed with asthma also have a component of dysfunctional
breathing. Breathing retraining involves assessment of breathing patterns, respiratory chemistry, and
triggers. Treatment is focused on education, breathing pattern awareness, learning new breathing
habits and trigger (stress) management. Breathing retraining allows an individual to take control of
their symptoms and employ simple and useful strategies to reach optimal functioning at work, at
home and at play.
Symptoms of Dysfunctional Breathing
 Shortness of breath
 Fatigue and weakness
 Reduced pain tolerance
 Poor concentration and memory
 Disturbed sleep
 Anxiety and worry
Signs of Dysfunctional Breathing
 Mouth breathing
 Accessory (chest) muscle use
 Frequent sighing
 Faster breathing rate
 Low blood CO2
 Voice changes/irritation
Locations
Calgary Winter Club Sport Physiotherapy
4611 14 Street NW
Calgary, AB T2K 1J7
403-289-0040
Glenmore Landing
A201, 1600 – 90 Ave SW
Calgary, AB T2V 5A8
403-460-5642
Additional information
Please allow for one hour for an assessment and wear comfortable clothing. During an
assessment your breathing will be observed and monitored non-invasively using
computerized equipment. Results will be analyzed and discussed with you, and a
treatment plan will be developed based on those findings and your needs.
www.breathenaturally.ca