Buteyko Canada Registration Form
Programs
 
*
= required field
Date of Course:
Location of Course:
Type of Course:

Personal Information
Name:*
Address:
City:*
Province:
Postal Code:
Telephone:*
Email Address: *
Date of Birth:
Occupation (or previous):
Hobbies/Activities:

Illness you are taking Buteyko for:
Select:
Other:
Degree of severity:
Illness due to:
Regularity of attacks/episodes:
Age originally diagnosed:
Most recent date hospitalized (for any reason):
Reason for hospitalization:
Most recent date you took cortisone/prednisone:
Medications for your condition:
Dosage (please be specific rather than 'as needed'):

For Sleep Apnoea:
Have you had a sleep study: Yes No
Do you have a sleep study copy: Yes No
When where you diagnosed:
How many episodes per hour:
Are you on CPAP machine: Yes No
When do you begin using it?:

Other Illnesses/Conditions:
Medications for those other conditions:
Are you pregnant: Yes No
Do you smoke: Yes No
Have you smoked: Yes No
If you do or have smoked, from when to when?

Have you suffered from:
Angina
High Blood Pressure
Low Blood Pressure
Diabetes
High Cholesterol
Migraines
Fluid Retention
Hypoglycaemia
Over-active Thyroid
Heart Condition
Kidney Disease
Under-active Thyroid
Other:


Many symptoms seem unrelated to over-breathing. Take this Hyperventilation Test to find your base line. You will be given another one at the course, to be filled out 2 weeks after its completion, to measure your improvement.
0 - never;
1 - rare;
2 - sometimes;
3 - often;
4 - very often

1 - Allergies or hayfever 0 1 2 3 4
2 - Bloated abdomen, flatulence or belching 0 1 2 3 4
3 - Deep breathing 0 1 2 3 4
4 - Holding your breath 0 1 2 3 4
5 - Rapid breathing 0 1 2 3 4
6- Mouth breathing 0 1 2 3 4
7 - Short of breath 0 1 2 3 4
8 - Chest constriction 0 1 2 3 4
9 - Upper chest breathing 0 1 2 3 4
10 - Chest pains unrelated to heart 0 1 2 3 4
11 - Cold hands or feet 0 1 2 3 4
12 - Colds, flus or chest infection 0 1 2 3 4
13 - Concentration is poor 0 1 2 3 4
14 - Forgetfulness, mental fatigue 0 1 2 3 4
15 - Constipation or diarrhea 0 1 2 3 4
16 - Coughing 0 1 2 3 4
17 - Many cavities 0 1 2 3 4
18 - Gum problems 0 1 2 3 4
19 - Depression 0 1 2 3 4
20 - Inability to take a deep breath 0 1 2 3 4
21 - Dry mouth 0 1 2 3 4
22 - Grinding teeth while asleep 0 1 2 3 4
23 - Exhausted upon waking 0 1 2 3 4
24 - Headaches 0 1 2 3 4
25 - Pounding or skipping heart 0 1 2 3 4
26 - High blood pressure 0 1 2 3 4
27 - Irritability 0 1 2 3 4
28 - Itchy or dry skin or lips 0 1 2 3 4
29 - Lightheaded or dizzy 0 1 2 3 4
30 - Loss of sex drive 0 1 2 3 4
31 - Excessive mucous production 0 1 2 3 4
32 - Muscle tension or cramping 0 1 2 3 4
33 - Nose that blocks 0 1 2 3 4
34 - Pain in bones 0 1 2 3 4
35 - Physical exhaustion 0 1 2 3 4
36 - Lack of stamina 0 1 2 3 4
37 - Sense of smell is reduced 0 1 2 3 4
38 - Sighing habitually 0 1 2 3 4
39 - Blocked or dripping nose 0 1 2 3 4
40 - Insomnia 0 1 2 3 4
41 - Apnoea 0 1 2 3 4
42 - Snoring 0 1 2 3 4
43 - Waking frequently at night 0 1 2 3 4
44 - Sweaty palms or feet 0 1 2 3 4
45 - Frequently hot 0 1 2 3 4
46 - Tension or apprehension without reason 0 1 2 3 4
47 - Throat clearing 0 1 2 3 4
48 - Tingling or numb fingers, toes or face 0 1 2 3 4
49 - Trembling or tics 0 1 2 3 4
50 - Visual disturbances such as flashes 0 1 2 3 4
51 - Poor night vision 0 1 2 3 4
52 - Yawning when not tired 0 1 2 3 4

 
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In checking this box I am signing my name to this document. The information given by me on this web form is accurate.

 

Course fees:

The cost is between $400 - $600 depending on location and circumstances. This includes GST. A $100 non-refundable registration deposit should be sent with the completed registration form to secure a place in the course. The balance should be paid on the first day of the course. To determine where to send the registration for the course in your area, and the specific fee for the course you are registering for, email us. Click here. A payment plan is available

Course includes: pre-consultation, 5 session course (10 contact hours), follow-up telephone call, unlimited on-going support, unlimited refreshers as needed.

If this registration form is for a child, the parent must sign the agreement at the first class of the 5-session course or workshop. This is unnecessary for the free talks.

Disclaimer:

I understand that:

1) The Buteyko breath retraining course is a series of lectures and exercises. It does not constitute medical treatment. I, the undersigned, agree to only modify prescribed medication after consultation with a medical doctor.

2) As I am not a trained Buteyko Practitioner, I will not attempt to teach other people without first completing the training according to the Buteyko Institute Method, the written permission of the Buteyko Institute of Breathing and Health and Buteyko Canada: Centre for Breathing Well.