REGISTRATION FORM
The information below is intended to assist the Educator to become familiar with your condition,
your expectations of the program and your current medical symptoms. Although any information
you complete is not intended to be shared with anyone but your Educator, you acknowledge that
you provide it freely and voluntarily for its intended use. This program is not a medical therapy,
nor should be used as a substitute for any medical treatment prescribed to you. If unsure, please
consult your primary care physician.
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:_______________________ Course location: _____________________________
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 Height ________
Current Weight __________
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?
___Angina
Y
___Epilepsy
Y
___High Blood Press. Y
___Hypoglycemia
Y
___Migraines
Y
___Schizophrenia
Y
___Other
N
N
N
N
N
N
Current?
___Depression
___Fluid retention
___High Cholesterol
___Kidney Disease
___Overactive Thyroid
___Underactive Thyroid
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Current?
___Diabetes
___Heart Condition
___Hyperventilation
___Low Blood Pressure
___Panic attacks
Y
Y
Y
Y
Y
N
N
N
N
N
Please list other symptoms on Page 3
Have you had any major surgeries?
YES ___
NO ___
Have you had any life threatening illnesses?
YES ___
NO ___
Drugs are you allergic to _________________________________________________
_______________________________________________________________
_______________________________________________________________
What things besides drugs are you allergic to? _______________________________
_______________________________________________________________
_______________________________________________________________
Females, are you pregnant? YES ___
NO ___
COMPLETE THIS PAGE IF YOU HAVE ASTHMA, COPD
NAME: _________________________
DATE: ____________
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:
Dosage
Albuterol
Alupent
Atrovent
Proair
Number of puffs
am
pm
Slow Release Relievers:
Dosage
Foradil
Serevent
Brovana
Zyflo
Number of puffs
am
pm
Preventers:
Inhaled
Aerobid
Asmanex
Azmacort
QVAR
Flovent
Intal
Pulmicort
Vanceril
Number of puffs
am
pm
Dosage
Nebulizer Use:
Dosage
Dosage
Number of puffs
am
pm
Dosage
Number of puffs
am
pm
Dosage
Number of tablets
am
pm
Combivent
Maxair
Proventil
Ventolin
Xopenex
Xolair
Theophylline
Symbicort
Spiriva
ADVAIR*
Tablet
Alvesco
Medrol
Prednisone
Singulair
Tilade
Combined drugs:
Symbicort
ADVAIR*
am
pm
Dosage
am
pm
AccuNeb
Xopenex
Albuterol
Atrovent
Ventolin
Duo Neb
Nasal Spray Use:
Dosage
Astelin
Rhinocort
Nasocort
Omnaris
am
pm
Dosage
am
pm
COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
OTHER MEDICATION NOT RELATED TO ASTHMA:
Medication
Condition
Dosage
Do you or did you ever smoke? YES ___
If yes, how many packs per day?_____
AM
PM
Comments
YES, have stopped ___ NO ___ If yes, how long? ____
If stopped, when did you stop smoking?___________
Please explain any surgeries:
____________________________________________________________________________
____________________________________________________________________________
If you checked a life-threatening illness:
How long ago was it?
Sleep apnea/ snoring
_____________________
Was it lung related?
YES ___
NO ___
Have you had a sleep study?
Yes ______
No ______
Was it kidney related?
YES ___
NO ___
Date of test: ______________
Was it heart related?
YES ___
NO ___
Results: __________________
Apneas noted: ____________
If you checked major surgeries:
How long ago was it?
_____________________
Oxygen saturation: _______%
Was it lung related?
YES ___
NO ___
CPAP pressure setting: ______
Was it kidney related?
YES ___
NO ___
Are you using oxygen? Y
What flow rate?
N
_______L/M
Was it heart related?
Do you have a blood disorder?
YES ___
NO ___
YES ___
NO ___ If yes, which? ________________________
Have you been diagnosed with any chronic condition? YES ___
Are you experiencing chronic pain?
YES ___
NO ___ If yes, which? __________
NO ___ If yes, where? ______________________
_______________________________________________________________________________________
COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
SYMPTOMS SUFFERED PRIOR TO COMMENCING COURSE
Please check your symptoms:
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) allergies
) anemia
) apathy
) asthma attacks
) bleeding veins
) breathing through mouth
) breathing without pause
) chest pains (not heart)
) constipation
) coughing
) deterioration of vision
) diarrhea
) dizziness
) dryness in mouth
) dryness of skin
) far sightedness
) fear of sultry air
) fear without reason
) flashes before eyes
) frequent deep breaths
) headaches
) impotence
) insomnia
) irritability
) lack of concentration
Please list other symptoms
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) loss of feeling in limbs
) loss of hearing
) loss of libido
) loss of memory
) loss of smell
) mental fatigue
) muscle pains
) painful/irregular periods
) pains in heart region
) pains in bones
) physical exhaustion
) prone to colds and flu
) rhinitis
) ringing or buzzing in ears
) short temper
) shortness of breath
) shuddering in sleep
) snoring
) sudden chilling of limbs
) tightness around chest
) trembling and tic
) varicose veins
) weight gain
) weight loss
) other
__________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please tell me about why you are attending the course and what you hope to gain from it:
____________________________________________________________________________
____________________________________________________________________________
I understand that the Buteyko Breathing Reconditioning 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.
By signing below, I acknowledge that I have read and agree to the Terms of the Payment Agreement.
I also agree and understand that by virtue of enrolling into this course, I will not become certified by the
Buteyko Breathing Educators Association and should not use my knowledge to attempt to teach and
educate others about this program, as one of the certified educators.
Name: ___________________________________.
Date: _________________
Signed: ______________________________________________
If client is under 18, a parent or guardian must sign this form