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John Murphy
Enzo Scarsella
Joanne McKee
Liam O’Rourke
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Bart Prinsen
Sara Robbins
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Health Screening Form
John Murphy
2020-07-14T20:36:06+00:00
“Complete the following intake form and register/inquire about our Workshops/5 Day Course/Private Course and Individual Breathing Assessments”
Breathing Health Screening Form
Step
1
of
7
14%
(all information is confidential and is used only as a screening tool in our clinic. Not meant to diagnose illness)
Date
MM slash DD slash YYYY
Name
First
Last
Phone
Email
1. List the reason(s) why you are interested in learning more about our breathing re-education services.
2. Please list ALL health concerns/issues (even if you don’t feel they are related to your breathing.) i.e. headaches, heart, blood pressure, blood sugar, neurological i.e. epilepsy etc… Note: asthma and sleep apnea questions are listed below.
If not listed above, please describe any significant injuries you are currently dealing with and/or previously.
3. Do you have asthma?
Yes
No
Uncertain
If so, for how long? Severity?
List current asthma medication, if any:
Have you ever been on steroids/prednisone? If so, when was the most recent course?
Have you ever been hospitalized for asthma or breathing issues? When?
4. Have you ever been diagnosed with sleep apnea or suspect you may have it
Yes
No
Uncertain
If yes, when were you diagnosed?
Have you ever had a sleep study and do you have a record of it?
Have you been prescribed a CPAP machine?
Yes
No
Do you still use it?
Yes
No
Have you ever smoked? If so, from when until when?
For women: are you pregnant?
Yes
No
Uncertain
If yes, how many weeks
Do you exercise? How frequently? How long? Type?
SYMPTOM TRACKER (INITIAL)
Please rate your symptoms accordingly: 0 – not applicable 1- rarely 2- sometimes 3- often 4- frequently If there is an * beside the symptom, please note number of episodes per day or week in the extra column
Wheezing/Chest tightness
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Blocked or stuffy nose
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Runny or drippy nose
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Re-current colds/flu
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Excess mucous production
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Coughing
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Mouth breathing (including exercise)
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Noisy/heavy breathing
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Rapid +/or Upper chest breathing
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Erratic breathing pattern
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Short of breath at rest
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Short of breath when talking
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Easily breathless on exertion
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Yawning (even if not tired)
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Breath holding
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Throat clearing
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Sighing or extra deep breaths
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Snoring/Irregular breathing
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Restless Sleep or Insomnia*
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Restless Sleep or Insomnia per week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Episodes per week.
Recalled wakings per night* (avg)
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Recalled wakings per night* (avg)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Episodes per day.
Waking self with gasp/snort
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Toilet visits at night*
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Toilet visits at night*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Episodes per day.
Grinding teeth at night
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Nightmares or vivid dreams
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Shuddering in sleep, restless legs
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Tired upon waking
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Waking with a headache
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Waking with a dry mouth or throat
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Pounding, erratic or fast heartbeat
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Feeling revved up or jumpy
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Tight feeling in chest
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Tension/apprehension/anxiety
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Tingling fingers, toes or face
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Chest pain unrelated to heart
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Lightheaded or dizzy
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Panic attacks
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Feeling ‘spaced out’ or confused
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Low attention span, concentration
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Poor memory, forgetful
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Irritability, anger easily
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Low mood, depression
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Headaches
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Migraine headache
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
High blood pressure
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Low energy/fatigue
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Sleepy all day, require a nap* (wk)
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Sleepy all day, require a nap* (wk)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Episodes per week.
Falling asleep sitting, reading, TV, car
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Muscle tension/achy
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Muscle spasm/tremors/twitching/tics
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Joint/bone pain
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Excessive sweating, sweaty palms/feet
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Cold hands and feet +/or Raynaud’s
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Visual disturbances i.e. flashes
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Poor night vision
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Tinnitus
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Itchy skin
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Dry lips
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Gut problems: bloated, belching, heartburn, IBS
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Constipation/Diarrhea
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Frequent or urgent urination
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Dental issues (bad breath, cavities, gums)
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
Loss of libido
0 - Not Applicable
1 - Rarely
2 - Sometimes
3 - Often
4 - Frequently
(all information is confidential and is used only as a screening tool in our clinic. Not meant to diagnose illness)
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