Dru Yoga Cape Town -Breathing Space Intake Form

Name

Surname

Phone number

Email

Occupation

Does your occupation require much TALKING or PHYSICAL EXERCISE?(required)

Yes No

Are you stressed during the day?(required)

Never Sometimes Often Very Often

Do you experience cold hands or feet?(required)

Never Sometimes Often Very Often

Do you notice yourself yawning regularly during the day?(required)

Never Sometimes Often Very Often

Do you breathe through your mouth during the night? (Do you wake up with a dry mouth?)(required)

Never Sometimes Often Very Often

Have you completed a Sleep Study? (required)

Yes No

If yes, give approximate date:

Have you been prescribed a CPAP machine? (required)

Yes No

Do you currently use it?

Yes No

Do you limit your intake of dairy foods? (required)

Yes No

Has this helped you?

Yes No

Do you smoke?(required)

Yes No

IF yes, how many cigarettes a day:

Coughing

Wheezing

Exercise Induced Asthma

Frequent Colds

Breathlessness at rest

Frequent Sighing

Frequent Yawning

Sleep Apnoea

Snoring

Tiredness

Insomnia /Broken Sleep

High Perceived Stress

Poor Concentration

Anxiety

Panic Attacks

Headaches

Achy Muscles

Tummy upset / IBS

Lower back pain

Excessive sweating

Feeling Tense

Blurred vision

Chest Wall Pains

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

Stiffness in fingers or arms

Unable to Breathe Deeply

Cold hands or feet

Thumping of the heart

Feeling of anxiety

Preventer

Daily does

Reliever

Daily does

Breathing Space Intake Form

Thank you for your response. ✨

Please indicate the level of severity of any of the symptoms that you experience in list below:

Nijmegen Questionnaire

If asthmatic please list Asthma medications you take