The Buteyko Institute Method of Breathing Retraining

Suzanne Wright Crain Studios, LLC                                                            

1420 S. Alamo, Ste. 106-4

San Antonio, TX

____________________________

Studio/Office (210) 496-5692

Cell (210) 363-3455

Email: thecosmicbody@gmail.com

REGISTRATION APPLICATION

PLEASE FILL IN ALL THE INFORMATION ON EACH OF THE 3 PAGES. Your information will be used to evaluate your suitability for the Buteyko Breathing class and will not become part of any other entity:

Name: Mr/Mrs/Ms/Miss  ...............................................................................................

Address: .....................................................................................................................

....................................................................................................................................

Telephone:                  work ................................            home ....................................

Occupation: .......................................................

Course location: ...................................................

Email: ………………………………………………………………………………………

MEDICAL HISTORY

Type of Illness:     .........................................................

Degree: (e.g. Mild) ...............................................................................

Regularity of attacks or problems:......................................................

Age Originally diagnosed: ...................  Current Age: .......................

Medical Practitioner: ..............................    Telephone: .....................

Last time hospitalized for illness: .....................................................

Date you last took cortisone orally or by injection

(e.g. Prednisone, Prednisolone, Methylprednisone): ...........................

Have you ever suffered from the following problems?

Heart Condition .......                           High Blood Pressure .......

Low Blood Pressure .......                    Epilepsy .......

Diabetes .......                                      Schizophrenia .......

Kidney Disease .......                           Depression .......

Under active Thyroid .......                  Over active Thyroid .......

Migraines .......                                    Hypoglycemia .......

High Cholesterol .......                         Fluid Retention .......

Angina.......    Other....................................................... ................................

What drugs are you allergic to? ......................................................................

..........................................................................................................................

What things besides drugs are you allergic to? ..............................................

.........................................................................................................................

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.

Reliever Medication:

                                                                                    Number of puffs/nebulizer

                                                Dosage                                    am                   pm

Atrovent puffer                        ..............................................................................

Atrovent nebulizer                   ..............................................................................

Bricanyl puffer                        ..............................................................................

Bricanyl turbohaler                  ..............................................................................

Combivent                              ..............................................................................

Foradil                                     ..............................................................................

Nuelin tablets/capsules           ..............................................................................

Oxis                                        ..............................................................................

Salbutamol                              ..............................................................................

Serevent                                 ..............................................................................

Theo-dur                                 ..............................................................................

Ventolin puffer                                    ..............................................................................

Ventadisk 200/400                  ..............................................................................

Ventolin nebulizer                    ..............................................................................

Volmax                                    ..............................................................................

Other............................           ..............................................................................

Preventer Medication:

Accolate                                  ..............................................................................

Becotide 100/200                    ..............................................................................

Becodisk 200/400                   ..............................................................................

Flixitide                                    ..............................................................................

Intal                                         ..............................................................................

Prednisone. . . . . . mg             ..............................................................................

Pulmicort 200/400                   ..............................................................................

Respocorte                             ..............................................................................

Singulair                                  ..............................................................................

Zyflo                                        ..............................................................................

Other............................           ..............................................................................

Combination Reliever & Preventer

Advair                                      ……………………………………………………….

Symbicort                               ……………………………………………………….

Other                                       ……………………………………………………….

Other Medication you take:

…………………………           ……………………………………………………...

....................................            ..............................................................................

....................................            ..............................................................................

....................................            ..............................................................................

                      SYMPTOMS SUFFERED PRIOR TO COMMENCING COURSE

                                               Please place tick in space provided

01 ( ) shortness of breath                    02 ( ) breathing through mouth                        

03 ( ) tightness around chest              04 ( ) frequent deep breaths

05 ( ) headaches                                 06 ( ) breathing without pause

07 ( ) dizziness                                    08 ( ) insomnia

09 ( ) loss of memory                         10 ( ) mental fatigue

11 ( ) lack of concentration                 12 ( ) short temper

13 ( ) irritability                                    14 ( ) apathy

15 ( ) ringing/buzzing in ear                 16 ( ) fear without reason

17 ( ) fear of sultry air                         18 ( ) trembling and tic

19 ( ) coughing                                    20 ( ) loss of feeling in limbs

21 ( ) impotence                                  22 ( ) dryness in mouth

23 ( ) far sightedness                          24 ( ) deterioration of vision

25 ( ) allergies                                     26 ( ) pains in heart region

27 ( ) asthma attacks                          28 ( ) painful/irregular periods

29 ( ) itching                                        30 ( ) muscle pains

31 ( ) dryness of skin                          32 ( ) rhinitis

33 ( ) loss of hearing                           34 ( ) prone to colds/flu etc

35 ( ) flashes before eye                     36 ( ) shuddering in sleep

37 ( ) snoring                                       38 ( ) loss of libido

39 ( ) weight loss                                 40 ( ) chest pains (not heart)

41 ( ) weight gain                                42 ( ) sudden chilling of limbs

43 ( ) varicose veins                           44 ( ) physical exhaustion

45 ( ) pains in the bones                      46 ( ) anemia

47 ( ) diarrhea                                     48 ( ) loss of smell

49 ( ) bleeding veins                            50 ( ) any symptoms not listed

Please list other symptoms.........................................................................................

................................................................................................................................

I understand that the Buteyko Breathing Recondition Program is a series of lectures and training. 

It does not constitute medical treatment.  Further more, I, the undersigned, agree to only modify

prescribed medication after consultation with a medical doctor.

I also agree that as I am not a trained Buteyko Practitioner I will not attempt to teach other people

without the written permission of Buteyko Breathing Educators Association.

Name: ...................................................................       Date: ..............

Signed: .................................................................................................

Signed -------------------------------------------------------------------------------

If patient is under 18 this form must be signed by a parent of guardian

e-mail this completed form to Suzanne Wright Crain at thecosmicbody@gmail.com. If you have questions concerning any part of this form please call or e-mail Suzanne.