Buteyko Breathing - Symptom Checklist - Jean Jarrett Natural Health

Choose the option that applies to you

Snoring

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Sleep apnoea (or do you use a CPAP machine or splint?)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Sinusitis/Nasal polyps/Hayfever

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Sneezing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Tightness in chest

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Shortness of breath

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Breathless on slight exertion

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Pins and needles /numbness/tingling (fingers, toes)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Poor concentration

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Poor memory

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Headaches

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Anxiety

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Irritable mood

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Racing heart

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Post nasal drip (mucus dripping down back of throat)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Asthma (medicated or not)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Blocked or stuffy nose

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Wheezing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Coughing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Cold hands and/or feet

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

High blood pressure (Or do you take medication for BP?)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Fatigue

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Insomnia

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Restless/ interrupted sleep

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Leg or muscle cramps

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Restless Legs

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Breathing through mouth

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Sighing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Sniffing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Throat clearing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Yawning

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Taking large breaths prior to talking

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Hearing breathing when at rest

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Noticeable movement of chest when breathing

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Holding of breath during day (Daytime apnoea)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Teeth grinding at night (Bruxism)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Teeth clenching and or TMJ pain

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Dry mouth

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Waking tired

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Irritable bowel syndrome

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Diarrhoea

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Constipation

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Reflux/Heartburn (Or do you take medication for GORD?)

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Stiff shoulders and neck muscles

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Burping

Nil/Never

Mild/Rarely

Moderate/Sometimes

Severe/Often

Do you suffer from asthma, snoring, obstructive sleep apnoea, nasal congestion, sinusitis and rhinitis or anxiety?

Take this questionnaire to find out if you have dysfunctional breathing

Jean Jarrett Natural Health