16.2b.p1-4 pcaci (page 1)

Pre-course Assessment & Client Information What is your most severe health problem or symptom? What was the deciding factor that led you to start our course? Name of the person who referrred or recommended us to you: BREATH POWER - Buteyko Training Services 16.2.B.P1 List age first diagnosed on left hand side and place an X in
the appropriate box M=Mild, S=Severe, VS=Very Severe Have you had your tonsils removed & when? Have you had your appendix removed & when? Do you wear glasses or contacts & when? Have you had any other major operations (please list) ? BronchiectasisCystic FibrosisEmphysemaCOAD or COPDFibrosing AlveolitisSleep Apnoea Have you had any major car accidents (please list) ? Multiple SclerosisAttention Deficit DisorderArthritisCancer Date of most recent hospitalisation and reason? Have you had any broken bones (please list)? Heart ConditionAnginaHigh Blood PressureTinnitusGout Do you have any known allergies to drugs? Irritable Bowel SyndromeEndometriosisKidney DiseaseSchizophrenia Others Consulted (eg Chiro, Physio, Naturopath etc): InsomniaMigraine HeadachesParkinsons DiseaseOther BREATH POWER - Buteyko Training Services 16.2.B.P2 Symptoms suffered prior to commencing program Place an X in the appropriate boxes for severity M=Mild, S=Severe, V=Very Severe & Frequency D=Daily, W=Weekly O=Occasionally
Sudden chilling of limbs & other parts Heart pounds easilyLoss of feeling in the limbs BREATH POWER - Buteyko Training Services 16.2.B.P3 # mins am noon pm Puffers/Turbohalers/Oral tablets Maximum number of times per day used when reqd I am aware that during this course I will be instructed in the Breath Power - Buteyko Technique of breathing reconditioning. It is then up tome to use these techniques in order to gain long term improvement. I fully recognise that breathing reconditioning requires much discipline and that if I, or my child/guardian, cease to use the technique that symptoms may return. I am aware that medication should bekept handy at all times in case of emergency. I accept full responsibility for my future use or non-use of these techniques and therefore fullresponsibility for any deterioration of health that may occur in the future.
I understand that the method taught to me or my child/ward is tailored to suit my condition/s and I agree not to teach the regimes to others.
I understand that the Breath Power - Buteyko Breathing Reconditioning Programme is a series of lectures and training in breathing recon-ditioning, and does not constitute medical treatment. Further more, I, the undersigned, agree to only modify prescribed preventative medication after consultation with a medical doctor.
The place of origin of this disclaimer agreement is the State of Western Australia, Australia and it shall be governed in accordance with thelaws of Western Australia. The courts of Western Australia shall be the forum for the resolution of any dispute arising hereunder.
If under 18 this form must be signed by a parent or guardian. BREATH POWER - Buteyko Training Services 16.2.B.P4

Source: http://www.buteyko.com.au/pdf/PCA.pdf