IF you have done a buteyko tasmania course and would like to send feedback, please download this form
Return it by email to caroline@buteykotasmania.com.au or post it to PO Box 573 WYNYARD TAS 7325
CONFIDENTIAL BUTEYKO INSTITUTE BREATHING METHOD QUESTIONNAIRE
Name: ___________________________________________ Age: _______
Telephone Number: ________________________ Date: _______________
1. What was the main symptom for which you did the Buteyko course (If there was more than one symptom, please list all symptoms): ______________________________________________________________________________________________________________________________________
(Please circle the appropriate answer.)
2. How would you describe your condition prior to commencing the Buteyko Method?
Mild Severe Very Severe
3. How would you describe your condition since learning the Buteyko Method?
Stable Improving Getting Worse
4. Does the Buteyko Method make sense to you?
Yes No Partially
5. How often do you apply the Buteyko Method?
A little Sometimes All the time
6. With what frequency do your symptoms occur on application of the Buteyko Method?
Less frequently Usual frequency More frequently
7. How much have you worked on your condition using the Buteyko Method?
Casually Moderately Diligently
8. What effects do you feel as a result of practicing the Buteyko Method? (Please circle, underline or highlight the effects you feel).
Less anxious Less tired More energy Appetite stabilized
Other - Please specify
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Are you more confident regarding the progress of your condition since using the Buteyko Method?
Yes No
10. Has your level of stamina increased?
Not noticeably Moderately Significantly
11. Did you find the Buteyko Method
Easy to master Difficult Extremely difficult
12. Would you recommend the Buteyko Method to other people?
Yes No
13. Any other comments?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I allow/do not allow this information to be used as testimonial for the Buteyko Method.
(Real names are NOT used in testimonials)
Signature: ______________________________________
Date: _________________________________________
Thank you for taking the time to fill in this questionnaire.
Please post to Caroline Ash PO Box 573 WYNYARD TAS 7325
or Email to caroline@buteykotasmania.com.au
or Ring/text Caroline to collect it [0459 465 995]
Name: ___________________________________________ Age: _______
Telephone Number: ________________________ Date: _______________
1. What was the main symptom for which you did the Buteyko course (If there was more than one symptom, please list all symptoms): ______________________________________________________________________________________________________________________________________
(Please circle the appropriate answer.)
2. How would you describe your condition prior to commencing the Buteyko Method?
Mild Severe Very Severe
3. How would you describe your condition since learning the Buteyko Method?
Stable Improving Getting Worse
4. Does the Buteyko Method make sense to you?
Yes No Partially
5. How often do you apply the Buteyko Method?
A little Sometimes All the time
6. With what frequency do your symptoms occur on application of the Buteyko Method?
Less frequently Usual frequency More frequently
7. How much have you worked on your condition using the Buteyko Method?
Casually Moderately Diligently
8. What effects do you feel as a result of practicing the Buteyko Method? (Please circle, underline or highlight the effects you feel).
Less anxious Less tired More energy Appetite stabilized
Other - Please specify
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Are you more confident regarding the progress of your condition since using the Buteyko Method?
Yes No
10. Has your level of stamina increased?
Not noticeably Moderately Significantly
11. Did you find the Buteyko Method
Easy to master Difficult Extremely difficult
12. Would you recommend the Buteyko Method to other people?
Yes No
13. Any other comments?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I allow/do not allow this information to be used as testimonial for the Buteyko Method.
(Real names are NOT used in testimonials)
Signature: ______________________________________
Date: _________________________________________
Thank you for taking the time to fill in this questionnaire.
Please post to Caroline Ash PO Box 573 WYNYARD TAS 7325
or Email to caroline@buteykotasmania.com.au
or Ring/text Caroline to collect it [0459 465 995]
