BUTEYKO INTAKE FORM

The 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.

Do you have a family history of:

Females:

Have you ever smoked?: