Buteyko Breathing   ●    Exercise       Nutrition       Sleep       Extras

Client Enrollment Form

Client Enrollment Form

Buteyko Plus - Client Enrollment Form

Parental approval is required if the client is under 18
A parent must be present at each session if the client is under 13

Please complete the questions below as accurately as possible so that your practitioner can assist you with your individual condition.

Parental approval required if under 18

Does it require much:
Please state which best describes your condition
Do you feel that deep breathing is good for you?
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?
Have you been prescribed a CPAP machine?
Do you currently use it?
Do you Smoke?
Do you limit your intake of dairy foods?
Has this helped you?
How many hours a week do you do physical exercise?
Please indicate the level of severity of any of the symptoms that you experience, in the list below.
Frequent sighs
Excessive sweating
Insomnia / Broken sleep
Frequent yawning
High perceived stress
Poor concentration
Exercise induced asthma
Sleep apnea
Tummy upset / IBS
Panic attacks
Frequent colds
Achy muscles
Breathlessness at rest
Lower back pain

If you suffer from asthma, please list the asthma medications you take

If less than once/day, make an estimate: e.g. "twice a month"
Female participants: Are you currently pregnant?
Some exercises are contraindicated
How did you hear about this course


You are requested to read the following carefully and to follow the instructions.

  1. If the participant is under 18 years old, this Disclaimer must be signed by a parent or legal guardian.
  2. You agree not to decrease or alter any medication or use of any medically prescribed device without prior consultation and approval of a medical doctor.
  3. You confirm that you have read and fully understand that failing to comply with these directions may pose a risk to your health or that of your dependent's and it will be against the recommendation of your instructor.
  4. You understand and agree that typing your name in the signature box below is the equivalent of a manual signature and is equally binding.
I acknowledge that typing my name in the box above is the legal equivalent of my manual signature.
Start Over