Patient’s Full Name
_______________________________________ Sex M F
If patient is a minor,1st attending Parent/Guardian Name
2nd attending Parent/Guardian Name _______________________________________
(please, provide at least one)
Med practitioner’s name ____________________
Med practitioner’s phone ___________________
Name/location of the clinic __________________
How did you hear about AsthmaCare?
Internet search Books (specify) ________________________
Primary reason for attending
Approximately, for how long you are having this condition? ________________________
Have you ever had the following
Heart disease EpilepsyHigh blood pressure SchizophreniaLow blood pressure
Diabetes Blood clots (thrombosis)Kidney disease
Sickle cell anemia Over Active ThyroidBrain tumour Arterial aneurysm
List any other illnesses you have
List medications you are currently taking for these illnesses
Do you experience any of the following
If female, are you currently pregnant?
Do you smoke?
Y / N
How many hours a week do you exercise?
is your primary reason for attending, please fill out this page
Approximate age of asthma diagnosis ______
What best describes your asthma
Asthma symptoms you are having
Number of hospitalizations during past 3 years ___________
What triggers your asthma symptoms
Do you symptoms get worse after
Dairy food intakeCold/Chest infectionsWeatherAirborne irritants (chemicals, pollutants, smoke etc…)
Please, circle asthma medication(s) and indicate dose you are currently taking on the nextCommonly used US ASTHMA MEDICATIONS
If you don’t see your medication(s) / brands there, please list it here
Commonly used US ASTHMA MEDICATIONS
RELIEVERS (short acting bronchodialators)
The course offered by Buteyko Clinic USA, LLC teaches the Buteyko Breathing Method through a program of lectures and training sessions. No partof this course constitutes medical treatment. Do not modify your current medical treatment or course of prescribed medications in any manner, orundertake this course with Buteyko Clinic USA, LLC before consulting with your health care provider.
Acknowledgements and Representations.
I understand and acknowledge that the instructor teaching this course is teaching a particular method, and is not in any way diagnosing ortreating any known condition that I may have.
I understand and acknowledge that the instructor teaching this course is not a medical practitioner or knowledgeable in prescribingmedication.
I understand and acknowledge that this course is not medical treatment, nor is it a substitute for medical treatment or advice.
I understand and acknowledge that I should consult my health care provider before undertaking this course or practicing any part of theButeyko Breathing Method.
I understand and acknowledge that I should consult my health care provider before modifying any current medical treatment or course ofmedication that may be prescribed to me before I undertake this course. If I modify my medication or treatment in any manner during orafter this course without first consulting my health care provider I take full responsibility for that decision.
If, at any time during this course, I have any concerns about my health or well being, I agree to notify my course instructor immediately. Iunderstand that I am free to leave the course at any time for any reason. If, during this course, or at any time after this course, I feel theneed for any assistance, medical or otherwise, I take full responsibility for communicating this, as well as for seeking appropriate care,including leaving this course and obtaining such appropriate care.
I understand and acknowledge that Buteyko Clinic USA, LLC makes no guarantees or warranties as to any results of this course that I mayexperience.
In partial consideration for the knowledge provided by Buteyko Clinic USA, LLC in its course, I hereby voluntarily agree to release Buteyko ClinicUSA, LLC and all instructors teaching the course offered by Buteyko Clinic USA, LLC from any and all claims that might arise by reason of illness,injury, or death resulting from my participation in the course offered by Buteyko Clinic USA, LLC so long as such illness, injury, or death is notcaused by an intentional, willful, or wanton act. I assume full responsibility for the risk of illness, injury or death and hold Buteyko Clinic USA, LLCand all of its instructions harmless from any liability thereof. Moreover, if I have requested or registered my minor child to participate in any courses,then the provisions of this Release shall apply with equal force to such child.
If I should have any claims against Buteyko Clinic USA, LLC in connection with the terms of this Release or otherwise, then I agree that Minnesotalaw shall govern and that the District Court for Hennepin County, Minnesota, shall have jurisdiction of the parties and the controversy. I also agree,should Buteyko Clinic USA, LLC so submit, to the submission of any such claims to binding arbitration in Hennepin County, Minnesota, under therules of the American Arbitration Association, and agree that the award of the arbitrator in such case shall be binding any may be enforced by anycourt. Similarly, I agree that any claim I file in a court of law may be removed by Buteyko Clinic USA, LLC to arbitration and I shall not contestsuch removal.
<A parent or guardian’s signature is required below for participants under 18.>
Gesellschaft der Kinderkrankenhäuser und Kinderabteilungen in Deutschland e.V. GKinD c/o DRK-Kinderklinik Siegen Postfach 100554 57005 Siegen Rundschreiben 4 / 2012 1. Info über neue Geschäftsführung. 1 2. Elternbefragung . 2 3. Fachtagung für dauerbeatmete Kinder und Jugendliche . 2 4. Fachtagung 23. und 24. Mai 2013 in Hannover . 2 5. Kodierschulung 2013 . 2 6. PKMS Austausch,
This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formattedPDF and full text (HTML) versions will be made available soon. Adverse drug reactions from psychotropic medicines in the paediatric population: analysis of reports to the Danish Medicines Agency over a decade BMC Research Notes 2010, 3 :176 Article type Submission date Acceptance date