Buteyko Breathing Form

Fill in this form before the first meeting with your Buteyko Breathing instructor.

When we receive the form we'll get in touch with you to setup the initial appointment via Skype, Facetime, WhatsApp or telephone.

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Name and Contact Info

Name *

Age *

Email *

Phone *

Skype / Whatsapp / Facetime

Address *

City *

Country *

Your Advanced Buteyko Instructor

Please fill in the name and email of your Advanced Buteyko Instructor (optional)

Name of Instructor

Email of Instructor

How should we contact you?

Please tell us how you want us to contact you. Should we use telephone, skype or email?

Telephone Skype Email

General Health

Tell us about your medical history. List the year, nature and results of treatments, surgeries, traumas, etc. *

Do you use any medications? List them with the dosage you are taking per day. *

Do you do any types of exercise? How intensive and how many hours per week? *

What is your main health concern and main reason to start with Buteyko Breathing? *

Chronic Diseases

Have you ever suffered from the following conditions and diseases? Do you suffer from them now? Please give full details below. For diseases you never suffered from, just leave the field empty.

High blood-pressure or pulse

Angina

Heart Condition

Heartburn, gastritis or ulcers

Constipation or diarrhea

Impotence, loss of libido

Eye problems, ocular hypertension

Skin problems: itching, eczema, psoriasis

Athletes' feet, candida

Kidney problems

Hypothyroidism, hyperthyroidism

Rheumatism, arthritis

Asthma, bronchitis, sinusitis

Emphysema, COPD

Sleep apnea, snoring

Allergies, hay fever, rhinitis

Hemorrhoids

Frequent cold or flu

Insomnia

Dry mouth, mouthbreathing

Muscle problems, backpain

Loss of feeling, tingling, cold or hot limbs

Hyperventilation, breathlessness, panting

Coughing, wheezing

Trembling, spasms or shuddering

Tightness around chest, chestpains

Weight gains or weight loss

Migraine headaches

Depression

Anxiety, baseless fears, panic attacks

Anemia, other blood problems

Varicose veins

Cancer

Epilepsy

Diabetes type 1 or 2

Hypoglycemia

Schizophrenia, fobias

Chronic fatigue

Mental fatigue

Sudden physical exhaustion

Tinnitus, buzzing ear

Irritability, short temper

Low concentration, hyperactivity, ADHD

Stress, feeling tense

If you are pregnant: since how many months?

Do you have any other diseases?
List any other diseases you suffer from

Terms and Privacy Policy

Scroll down to read our privacy policy and terms

Buteyko Breathing is an individually personalized, gradual training system. Doing a Buteyko Breathing course does not qualify students to teach or guide others: It can have a negative impact if not controlled by a qualified instructor.

The Advanced Buteyko Institute does not share our users personal information with third parties. We only use it to enable users to login to the app and help our instructors give students personalized instruction, advice and support.

Students should always consult their doctor before engaging in Buteyko Breathing: the activities may be too strenuous or dangerous for some people.

Students signing up for a course agree not to hold drs. Eduard J.A. Reuvers, the Advanced Buteyko Institute, Advanced Buteyko instructors (as listed on the advancedbuteyko.com website) nor any other persons associated with the Advanced Buteyko Institute and website and apps accountable for any damages, liabilities, and losses that may be incurred during or resulting from courses offered by the Advanced Buteyko Institute.

Check the box to agree