Respiratory Muscle Strength Training Assessment Form
Complete this assessment to help determine your suitability and baseline status for respiratory muscle strength training.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Other
Prefer not to say
Reason for Assessment
*
Please Select
Medical referral
Personal interest
Athletic performance
Rehabilitation
Other
Do you currently experience any of the following symptoms? (Select all that apply)
*
Shortness of breath
Cough
Wheezing
Chest tightness
None of the above
How would you rate your current breathing comfort during daily activities?
*
1
2
3
4
5
Please indicate the frequency of the following symptoms in the past week.
*
Rows
Never
Rarely
Sometimes
Often
Always
Shortness of breath
1
2
3
4
5
Fatigue with exertion
6
7
8
9
10
Difficulty taking deep breaths
11
12
13
14
15
How confident are you in your ability to complete a respiratory muscle strength training program?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Have you previously participated in respiratory muscle strength training?
*
Yes
No
Please describe any relevant medical history or conditions that may affect your respiratory function.
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