Client Intake Form

My coaching approach is tailored to your specific requirements.

Let’s get started

Please complete the form answering all questions honestly.

This will take approx. 5 minutes.

Step 1 of 7

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About you

Your name

First Last

Your email

Your contact number

Your occupation

Does it require much TALKING or PHYSICAL EXERCISE?

Talking

Physical Exercise

Other

Please give additional details if appropriate

About you cont.

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?

Never

Sometimes

Often

Very often

Do you wake up with a dry mouth?

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

What is your BOLT score?

Measure your BOLT score (i.e. 11 seconds)

Exhale through the nose, pinch the nose with your fingers and count how many seconds until the first definite desire to breathe. You can read this post or watch this video for a detailed guide.

Complaints

Please indicate the level of severity of any of the symptoms that you experience in the list below: 1 = Mild, 2 = Moderate, 3 = Severe

Coughing

Mild

Moderate

Severe

Wheezing

Mild

Moderate

Severe

Exercise Induced Asthma

Mild

Moderate

Severe

Frequent Colds

Mild

Moderate

Severe

Breathlessness at rest

Mild

Moderate

Severe

Frequent Sighs

Mild

Moderate

Severe

Sleep Apnoea

Mild

Moderate

Severe

Frequent Yawning

Mild

Moderate

Severe

Snoring

Mild

Moderate

Severe

Lower back pain

Mild

Moderate

Severe

Excessive sweating

Mild

Moderate

Severe

High Perceived Stress

Mild

Moderate

Severe

Tummy upset / IBS

Mild

Moderate

Severe

Achy Muscles

Mild

Moderate

Severe

Tiredness

Mild

Moderate

Severe

Insomnia /Broken Sleep

Mild

Moderate

Severe

Poor Concentration

Mild

Moderate

Severe

Panic Attacks

Mild

Moderate

Severe

Headaches

Mild

Moderate

Severe

Migraines

Mild

Moderate

Severe

Allergies

Mild

Moderate

Severe

Please indicate any other common symptoms/condition that you may experience

Nijmegen Questionnaire

The Nijmegen questionnaire is used to screen patients with dysfunctional breathing such as hyperventilation syndrome.
Please indicate the level of severity of any of the symptoms that you experience in the list below:

Complaint

	Never	Rarely	Sometimes	Often	Very often
Chest wall pains
Feeling tense
Blurred vision
Dizzy spells
Confusion, losing contact with reality
Fast or deep breathing
Shortness of breath
Tightness in the chest
Bloated feelings in stomach
Tingling of fingers
Unable to breathe deeply
Stiffness in fingers or arms
Stiffness around the mouth
Cold hands or feet
Thumping of the heart
Anxiety

(A score of over 23 out of 64 suggests a positive diagnosis of hyperventilation syndrome)

Release of Claims, Assumption of Risk and Indemnification

Your name/Company name

By signing this form, you will agree to certain restrictions on your legal rights. Please read it carefully before signing. Please feel free to consult with your own attorney before signing.

Please check the following statements confirming you understand and accept the terms

I understand that the instructor teaching the Technique is not a medical practitioner or knowledgeable in prescribing medication.

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.

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 Advantage 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.

Signature

Print Name Legibly

Date

MM slash DD slash YYYY

Parent or legal guardian's signature is required below for participants under age 18

Signature

Print Name Legibly

Date

MM slash DD slash YYYY

Final question, to help me improve my services

How did you hear about this course?

Social media

Friend/Relative

OxygenAdvantage.com

Google search

Radio/TV/Printed advert

Healthcare practitioner

Other

“Charlotte’s practices are insightful.
Her coaching, breathwork, and cold practices have each taught me something new.”