First Name
*
Last Name
*
Email
*
Phone
*
Occupation
Please indicate if your occupation involves excessive:
Talking
Physical Movement
Please give additional details if appropriate:
Are you stressed during the day?
*
Never
Sometimes
Often
Very Often
Do you experience cold hands or feet?
*
Never
Sometimes
Often
Very Often
Do you notice yourself yawning regularly during the day?
*
Never
Sometimes
Often
Very Often
Do you breathe through your mouth during the night? (Do you wake up with a dry mouth?)
*
Never
Sometimes
Often
Very Often
What is your BOLT score? Exhale through nose. Pinch nose with fingers and count how many seconds until first definite desire to breathe.
*
How many hours a week do you partake in physical exercise?
*
Less than one hour
1-2 hours
2-3 hours
3-4 hours
4-5 hours
5-6 hours
6-7 hours
7 or more
Coughing
*
1
2
3
None
Wheezing
*
1
2
3
None
Exercise Induced Asthma
*
1
2
3
None
Frequent Colds
*
1
2
3
None
Breathlessness at Rest
*
1
2
3
None
Frequent Sighs
*
1
2
3
None
Frequent Yawning
*
1
2
3
None
Sleep Apnoea
*
1
2
3
None
Snoring
*
1
2
3
None
Lower back pain
*
1
2
3
None
Excessive sweating
*
1
2
3
None
High Perceived Stress
*
1
2
3
None
Tummy upset / IBS
*
1
2
3
None
Achy Muscles
*
1
2
3
None
Tiredness
*
1
2
3
None
Insomnia /Broken Sleep
*
1
2
3
None
Poor Concentration
*
1
2
3
None
Panic Attacks
*
1
2
3
None
Headaches
*
1
2
3
None
Chest Wall Pains
*
0
1
2
3
4
Feeling Tense
*
0
1
2
3
4
Blurred vision
*
0
1
2
3
4
Dizzy Spells
*
0
1
2
3
4
Confusion, losing contact with reality
*
0
1
2
3
4
Fast or deep breathing
*
0
1
2
3
4
Shortness of breath
*
0
1
2
3
4
Tightness in the chest
*
0
1
2
3
4
Bloated Feelings in Stomach
*
0
1
2
3
4
Tingling of fingers
*
0
1
2
3
4
Unable to Breathe Deeply
*
0
1
2
3
4
Stiffness in fingers or arms
*
0
1
2
3
4
Stiffness around the mouth
*
0
1
2
3
4
Cold hands or feet
*
0
1
2
3
4
Thumping of the heart
*
0
1
2
3
4
Anxiety
*
0
1
2
3
4
Total Score:
*
Please indicate any other common symptoms/condition that you may experience:
How did you hear about this course?:
*
Social Media
Friend
OxygenAdvantage.com
Internet Search
Radio
Health Care Practitioner
Other
I understand that the instructor teaching the Technique is not a medical practitioner or knowledgeable in prescribing medication.
*
Yes
No
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. I understand that I am free to leave the course at any time for any reason. If during the course or at any time after this course, I feel the need for any assistance, medical or otherwise, I take full responsibility for communicating this as well as for seeking appropriate care including leaving the course and obtaining such appropriate care.
*
Yes
No
If I am a female, I will ensure I am not pregnant before starting and during the Technique training and exercises. If I am pregnant I will discuss this with my Oxygen Research Institute Ltd instructor prior to starting the course and exercises. If I become pregnant or believe I may be pregnant while taking this training, I will stop all Technique exercises and inform my Oxygen Research Institute Ltd instructor immediately.
*
Yes
No
Signature
*
Clear
Parent or legal guardian's signature is required below for participants under age 18
Clear
By providing your phone number, you consent to receive text messages and phone calls from Level Up Your Life Pty Ltd, including its brands Loz Life and The Mojo Mentor. These communications may include automated, pre-recorded, or AI-generated voice messages. You consent to receive marketing communications from us, including updates, promotional offers, and information about our programs and services. Message and data rates may apply. You may opt out of text messages at any time by replying STOP or contacting us directly. You may opt out of calls by letting us know during a call or by emailing team@lozlife.com . Important Note: These requirements reflect common legal standards, but laws may vary by jurisdiction. You are responsible for ensuring that your consent language complies with all applicable laws. We recommend reviewing this language with qualified legal counsel before use.
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