OA Assessment Form | SmartFit Health & Wellness

The Oxygent Advantage Individual Assessment

First name

Last name

Email

Occupation

Please indicate if your occupation or lifestyle involves excessive*

Talking

Physical Movement

Neither

Rate your daily stress level

Never

Sometimes

Often

Very Often

Do you experience cold hands or feet?

Never

Sometimes

Often

Very Often

Do you notice yourself yawning regularly during the day?

Never

Sometimes

Often

Very Often

Do you breathe through your mouth during the night? (Do you wake up with a dry mouth?)

Never

Sometimes

Often

Very Often

How many hours per week do you partake in physical exercise?*

Please indicate the level of severity for any of the symptoms below.

Coughing

Mild

Moderate

Severe

None

Wheezing

Mild

Moderate

Severe

None

Exercise Induced Asthma

Mild

Moderate

Severe

None

Frequent Colds

Mild

Moderate

Severe

None

Breathlessness at Rest

Mild

Moderate

Severe

None

Frequent Sighs

Mild

Moderate

Severe

None

Frequent Yawning

Mild

Moderate

Severe

None

Sleep Apnaea

Mild

Moderate

Severe

None

Snoring

Mild

Moderate

Severe

None

Lower Back Pain

Mild

Moderate

Severe

None

Excessive Sweating

Mild

Moderate

Severe

None

High Perceived Stress

Mild

Moderate

Severe

None

Stomach Upset / IBS

Mild

Moderate

Severe

None

Achy Muscles

Mild

Moderate

Severe

None

Tiredness

Mild

Moderate

Severe

None

Insomnia / Broken Sleep

Mild

Moderate

Severe

None

Poor Concentration / Inability to Focus

Mild

Moderate

Severe

None

Panic Atatcks

Mild

Moderate

Severe

None

Headaches

Mild

Moderate

Severe

None

Total your score using the Nijmegen Questionnaire below, to see if you could be experiencing hyperventilation syndrome.

Chest Wall Pains

0 Never

1 Rarely

2 Sometimes

3 Often

Feeling Tense

0 Never

1 Rarely

2 Sometimes

3 Often

Blurred Vision

0 Never

1 Rarely

2 Sometimes

3 Often

Dizzy Spells

0 Never

1 Rarely

2 Sometimes

3 Often

Confusion, losing contact with reality

0 Never

1 Rarely

2 Sometimes

3 Often

Fast breathing or need to take deep breaths

0 Never

1 Rarely

2 Sometimes

3 Often

Shortness of Breath

0 Never

1 Rarely

2 Sometimes

3 Often

Tightness in the Chest

0 Never

1 Rarely

2 Sometimes

3 Often

Bloated Feelings in Stomach

0 Never

1 Rarely

2 Sometimes

3 Often

Tingling of Fingers

0 Never

1 Rarely

2 Sometimes

3 Often

Unable to Breathe Deeply or Take a Deep Breath

0 Never

1 Rarely

2 Sometimes

3 Often

Stiffness in Fingers or Arms

0 Never

1 Rarely

2 Sometimes

3 Often

Cold Hands or Feet

0 Never

1 Rarely

2 Sometimes

3 Often

Anxiety

0 Never

1 Rarely

2 Sometimes

3 Often

[N.B.A score of over 23 out of 64 suggests a positive diagnosis of hyperventilation syndrome]

Total Your Score: