Mindfulness-Based Stress Reduction (MBSR) Participant Information Form
Dear Participant,

By completing this form, you will help me to be a more effective group leader. Please mark anything which does not apply to you as “N/A.” All information will remain strictly confidential.
Email address *
Personal Information
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Phone #1 *
Your answer
Phone #2
Your answer
Emergency Contact *
Your answer
Their Relationship to You *
Your answer
Their Phone # *
Your answer
Your Occupation *
Your answer
Household Members (examples: I live with my husband and two daughters. Or, it's just me and my dog Buster.) *
Your answer
Health/Wellness
Please answer the following as best you can. Remember that all information will be kept confidential.
Have you had any major illnesses, hospitalizations, or surgeries within the past 10 years? Please list chronologically. *
Your answer
Please list any prescribed medications you are currently taking and what they are for. *
Your answer
Are you currently under the care of a psychiatrist, psychotherapist, or mental health counselor? *
Required
Average hours of sleep daily *
Your answer
What is the quality of your sleep? *
Your answer
How often do you exercise? What kind? *
Your answer
Do you have any physical limitations or mobility issues? If yes, please describe. *
Your answer
Do you smoke? *
Do you have a history of substance abuse or addiction? *
What is your experience with meditation? *
Please list something you care about deeply. Be as specific as possible. *
Your answer
What are 3 things that give you pleasure in life? Be as specific as possible. *
Your answer
What are 3 of your greatest anxieties? Be as specific as possible. *
Your answer
Is there anything else you want me to know about you?
Your answer
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