Asthmacare.us

AsthmaCare Program
Workshop Date
Workshop location
The purpose of this form is to assist AsthmaCare practitioner to provide you with more individual program for yourspecific needs. We would like to remind you that any information released to AsthmaCare program (Buteyko ClinicUSA, LLC) is never sold or shared without your consent. Full Privacy Policy is available at .
Patient’s Full Name
_______________________________________ Sex M F
If patient is a minor,
1st attending Parent/Guardian Name
_______________________________________
2nd attending Parent/Guardian Name _______________________________________
Age _______
Occupation _________________________________________
Contact (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) ________________________ Advertisement (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?
If Asthma 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 next
Commonly used US ASTHMA MEDICATIONS sheet.
If you don’t see your medication(s) / brands there, please list it here Commonly used US ASTHMA MEDICATIONS
Generic name
Inhaler’s Color
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.>

Source: http://www.asthmacare.us/Images/Release%20(Buteyko%20Clinic%20USA).pdf