IMPORTANT: Click panel header to expand/collapse questionnaire in each panel. ***All FIELDS ARE REQUIRED.***
Demographics

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Last Name:
 
Age (16-100):
   
Gender:
 
Occupation:
 
Exercise Date:
 


Past Medical History

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Have you been diagnosed with (check all that apply):

1) A breathing condition:   If other, please explain:
2) A heart condition:  

If other, please explain:
3) A neurologic condition:  

If other, please explain:

4) Behavioral Health:   If other, please explain:

5) Currently or previously evaluated by behavioral health for a personal or professional issue or concern?  

6) Heightened feelings of stress within the past 2-4 weeks:  

7) Sleep:  


If other, please explain:


Current Medications

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1) Prescription:  

2) Inhalers:  

3) Sleep Aids or Sleeping pills  

4) Over the Counter (OTC): (including cold medicines, allergy medications, Tylenol, Motrin, and Vitamins/Herbs):  

5) Supplements: (includes protein powders, energy drinks, pre-/post-workout supplements, weight loss/gainer formulas):  

6) Other:  


Nijmegen Questionnaire (NQ)

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Certain breathing disorders cause symptoms outside the chest.
We appreciate your honest assessment in answering the following questions:


Symptom
Never - 0
Rarely – 1
Sometimes – 2
Often – 3
Very Often – 4

 
Chest Pain:
 
Feeling Tense:
 
Blurred Vision:
 
Dizzy Spells:
 
Feeling Confused:
 
Faster/Deeper Breathing:
 
Short of Breath:
 
Tight Feelings in Chest:
 
Bloated Feeling in Stomach:
 
Tingling Fingers:
 
Unable to Breath Deeply:
 
Stiff Fingers or Arms:
 
Tight Feelings around Mouth:
 
Cold Hands or Feet:
 
Palpitations:
 
Feelings of Anxiety:

1) Occurrence: Do you notice your symptoms occur in any particular pattern, time of day, or circumstance? ( check all that apply)   If other, please explain:

2) Any known triggers? (check all that apply)   If other, please explain:

3) If symptoms occur predominantly with exercise, at what point in the engagement of the physical exercise do they occur?  







If other, please explain:


Exercise Patterns

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1) How many days/week (1-7) do you exercise (with exercise being defined as engaging in a physically rigorous activity for at least 30 minutes or more continuously with the sole purpose of improving either cardiovascular conditioning or muscular strength . **Exercise does NOT include the number of steps walked during the work day as part of normal movement/routine.  
2) How many minutes for each session do you average (1-360)?  
3) What forms of exercise do you engage in? (check all that apply)  
a)Aerobic
If other, please explain:

b) Strength Training
If other, please explain:




If other, please explain:


Breathing Patterns

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1) Do you ever notice yourself intermittently taking deep breaths or sighing throughout the day?  
2) Do you notice whether you initiate your breath from your chest or your abdomen? (check all that apply)  
3) Do you ever find yourself using your abdominal muscles to help you fully exhale?  
4) Do you notice your breathing patterns fluctuate throughout the day or during specific circumstances?   If Yes, check all that apply: If other, please explain: