WELCOME TO THE PROGRAM Please complete this participant registration form to complete registration. Participant Information Name* First NameLast Name Birth Date* -Month -DayYearDate Gender* MaleFemale Phone Number* Email* example@example.com Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code How did you hear about this program?* Please Select Social Media Friend Newspaper Gp or Consultant Internet Search Radio Health Care Practitioner Please indicate which session group would you like to be apart of? Mondays 6:30PM - 8:00PM ESTTuesdays 9:00AM-10:30AM EST Back Next Participant Intake Form Please complete the questions below as accurately as possible so that your practitioner can assist you with your individual condition. Occupation Does it require much talking or physical exercise? What condition/symptoms do you have? When were you first diagnosed with your condition? -Month -DayYearDate Please state which best describes your condition? Please Select Sometimes have symptoms Continuous symptoms (mild) Continuous symptoms (moderate) Continuous symptoms (severe) How often have you been admitted to hospital for asthma attacks/or other, in the past three years? Do you feel that deep breathing is good for you? YesNo Back Next Please select a response for each. Never Sometimes Often Very Often Do you feel stressed, anxious regarding your condition? Is your nose blocked? Do you breathe through your mouth during the day? Do you breathe through your mouth during the night?(Do you wake up with a dry mouth?) Have you completed a Sleep Study? YesNo If Yes, give approximate date: -Month -DayYearDate Have you been prescribed a CPAP machine? YesNo Do you currently use it? YesNo Do you Smoke? YesNo If Yes, How many cigarettes a day? How many glasses of pure water do you drink each day (approx.)? Do you limit your intake of dairy foods? YesNo Has this helped you? YesNo How many hours a week do you partake in physical exercise? Please Select Less than one hour 1-2 hours 2-3 hours 3-4 hours 4-5 hours 5-6 hours 6-7 hours 7 or more hours Back Next Symptom Overview Please indicate the level of severity of any of the symptoms that you experience in list below. 1 = Mild, 2 = Moderate, 3 = Severe 1 2 3 Coughing Wheezing Exercise induced asthma Frequent Cold Breathlessness at rest Frequent Sighs Frequent Yawning Sleep Apnoea Snoring Lower Back Pain 1 = Mild, 2 = Moderate, 3 = Severe 1 2 3 Excessive Sweating High Perceived Stress Tummy upset/IBS Achy Muscles Tiredness Insomnia/Broken Sleep Poor Concentration Panic Attacks Headaches Please indicate the level of severity of any of the symptoms that you experience in list below: Never Rarely Sometimes Often Very Often Chest Wall Pains Feeling Tense Blurred vision Dizzy Spells Confusion, losing contact with reality Fast or deep breathing Shortness of breath Tightness in the chest Bloated Feelings in Stomach Tingling of fingers Unable to Breathe Deeply Stiffness in fingers or arms Stiffness around the mouth Cold hands or feet Thumping of the heart Feeling of anxiety Please indicate any other common symptoms that you may experience: Back Next Please list Asthma medications you take: Preventer Daily Dose Reliever Daily Dose List any other illness you have: Medication For Female participants: Please tell the practitioner if you are currently pregnant. YesNo Back Next Primary Care Provider Information Provider Name Phone Number Pulmonologist or other Specialist Name: Phone Number Medical Health Practitioner Name Phone Number Please indicate if you have any concerns: Back Next Disclaimer and Waiver Please read the Boundless Breath, LLC Breathwork Release of Liability, Waiver and Assumption of Risk Agreement in its entirety before agreeing to terms. Signature Powered by Jotform Sign Clear SubmitSubmit Should be Empty:
