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
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