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Is Your Breathing Helping
or Harming You?
Take this free test to find out how functional your breath really is.

I created this questionnaire for you based on the Nijmegen Respiratory Health Test.

After completing it, you’ll receive an evaluation of your breathing pattern health scale by email.

What is your name?

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What is your email adress?

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What are problems you're dealing with?

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How often do you feel these symptoms?

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(0-never, 1-rare, 2-sometimes, 3-often, 4-very often)

Chest pain (sore chest wall)

How often do you feel these symptoms?

0

1

2

3

4

Blurred Vision (fuzzy eyes)

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0

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2

3

4

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Feeling Tense (physical tention)

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0

1

2

3

4

*

Dizzy Spells

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0

1

2

3

4

*

Feeling Confused

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0

1

2

3

4

*

Tight Feelings in Chest

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0

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2

3

4

*

Faster/Deeper Breathing

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0

1

2

3

4

*

Bloated Feeling in Stomach

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0

1

2

3

4

*

Unable to Breathe Deeply (sighing a lot)

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0

1

2

3

4

*

Tingling Fingers

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0

1

2

3

4

*

Tight Feelings around Mouth

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0

1

2

3

4

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Stiff Fingers or Arms

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0

1

2

3

4

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Cold Hands or Feet

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0

1

2

3

4

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Feelings of Anxiety (busy brain)

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0

1

2

3

4

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Heart racing (Palpitations)

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0

1

2

3

4

How often do you feel these symptoms?

*

(0-never, 1-rare, 2-sometimes, 3-often)

Wheezing (loud breathing)

How often do you feel these symptoms?

0

1

2

3

Mouth breathing during the day

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0

1

2

3

*

Asthma

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0

1

2

3

*

Snoring

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0

1

2

3

*

Mouth breathing at night

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0

1

2

3

*

Sleep apnea

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0

1

2

3

*

Frequent colds

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0

1

2

3

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Shortness of breath at rest

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0

1

2

3

*

Respiratory allergies

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0

1

2

3

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Excessive sweating

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0

1

2

3

*

A lot of stress

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0

1

2

3

*

Poor sleep, insomnia

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0

1

2

3

*

Panic attacks

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0

1

2

3

*

Headaches

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0

1

2

3

*

Poor concentration

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0

1

2

3

*

Fatigue

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0

1

2

3

*

Would you like to tell me something more about you?

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