Client Information Form

Please complete the below client information form for your upcoming class.  

If you have not done so already you can secure your place by calling 02 6296 2627

Any questions please email: info@betterbreathing.net.au

Personal Details

Health History

Current Medication

Sleep Disorder Breathing Treatments and Appliances

Symptom Tracker

INSTRUCTIONS: COMPLETE SELF ASSESSMENT COLUMN ONLY

The symptoms listed below have been associated with incorrect breathing. It is not uncommon to have 15 or more different symptoms. Please rate each individual symptom you experience at least once a week, or which are significant at certain times of the year with the “tick system". In the "Self-Assessment” column, enter today’s date then rate each of your symptoms as to how they are currently, before you commence breathing training. We can then track and assess your progress. Assessments 1, 2 and 3 will be completed after breathing training. 

RATE your symptoms - Score their intensity or incidence:

0 = Never
1 = intermittent symptoms, not every day. 
2 = symptoms present part of most days or nights.
3 = symptoms virtually all of each day or night. 
4 = symptom present all day or night and severe.

 

Respiratory and sleep-related

Musculoskeletal

Circulation / Cardiovascular

Neurovascular

Psychological / Nervous System

Digestion

General

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