VocalEase Courses

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VocalEase Courses

A group supported by Asthma+Lung UK to help people with respiratory or cardiac conditions, or fibromyalgia manage their breathing through singing. By submitting this form, you are accepting a place on the 6-week course advertised. The cost is £30 for the six-weeks, paid at the first session. If you change your mind once you have submitted your form, please let Ann know at ann.clewlow@btinternet.com, as spaces are limited. Please answer all the questions.

Name *

Email address *

Age *

Address *

Contact phone number *

Emergency contact number and name *

Medical diagnosis - please select all that apply to you *

COPD

Bronchiectasis

Asthma

Interstitial lung disease

Pulmonary fibrosis

Lung cancer

Fibromyalgia

Heart condition (please specify in the next section)

Other (please specify in the next section)

Required

Any other medical condition relevant to your participation in VocalEase sessions *

Breathlessness - please select which sentences best describe your current experience of breathlessness. *

Not troubled by breathlessness, except with strenuous exercise

Troubled by shortness of breath when hurrying or walking up a hill

I walk slower than people of the same age due to breathlessness, or might have to stop for breath when walking at my own pace on the level.

I stop for breath after walking about 100m or a few minutes on level ground

I'm often too breathless to leave the house or breathless when dressing/undressing

Required

Have you ever attended any of the following *

Pulmonary rehabilitation course

Another singing group or choir

None of the above

Required

Which GP surgery do you attend? *

How did you hear about VocalEase? *

In order to promote VocalEase photos and videos may occasionally be taken. Please give your consent for the use of your image below *

Yes, I give my permission for my image to be used

No, I don't give my permission for my image to be used.

Data protection. Your privacy is important to VocalEase. Information is held by the singing leader for administration and safety purposes only and will not be shared with any other parties without your prior consent. Information provided by you is stored on a password protected computer and will be deleted once notification to cease attending is given. Please write your name below to show you have read this statement. *

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