PWHT Registration Form
The International Association of Human Values (
www.IAHV.org
) is a non-profit educational and humanitarian foundation that has provided stress management, humanitarian and trauma-relief programs in the United States and worldwide in areas of trauma, conflict, and natural disaster. THIS FORM WILL BE KEPT CONFIDENTIAL
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Email address
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Power Breath Workshop Part 1 Jan 19 - 21st / Part 2 Jan 26 - 28th, Hours - 2:00 - 4:30pm CST. Teacher: Pam Brockman
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First Name
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Your answer
Last Name
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Your answer
Address
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City
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Your answer
State
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Your answer
Zip
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Home Phone
Your answer
Cell Phone
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Your answer
Work Phone
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Emergency Contact & Phone
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Your answer
Email
Your answer
Occupation
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Date of Birth (Must be at least 18 years old)
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YYYY
Gender
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Male
Female
Other
Participant Designation
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Military
Family
Significant Other
Service Provider
Branch of Military Service (only Veteran need respond)
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Air Force
Army
Coast Guard
Marine Corps
Navy
Military Status
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Active Duty
Veteran
Reservist
National Guard
Retiree
Rank
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Deployment information (optional)
Your answer
How did you hear about the course?
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Briefly describe your mental and physical health
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Your answer
Please indicate if you have any of these conditions:
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Asthma
Diabetes
Emphysema
seizures/Epilepsy
Heart Disease
Stroke
Bi-polar
High Blood Pressure
Depression
Anxiety / Panic disorder
Traumatic Brain Injury
Pregnancy
NONE
Required
If you are you presently under the care of a physician, or psychiatrist, or have been recently hospitalized, please describe :
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Please list any health problems or recent health concerns (mark N/A if none):
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Please describe in detail medications you are taking:
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Please list dates, course name and experiences with any meditation techniques or other self-development courses/techniques you have done
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Agreement
It is compulsory to attend all sessions of the course. Taking notes and use of tape recorders is prohibited. Agreement: I understand that any benefits derived from this course depend upon the extent of my participation. I therefore accept full responsibility for the outcome and I willingly agree to follow all instructions and participate fully. I also agree that I will not disclose the content of this course to anyone. I further agree that I will not attempt to instruct others in any of the techniques used in the course until such time as I receive personal training from Project Welcome Home Troops or IAHV. By entering my name and date below I agree to the above.
Signature
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Today's Date
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Military Stress Checklist (Veteran and military only)
Instructions: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully and click the appropriate bubble to indicate how much you have been bothered by that problem in the last month. Please use the following scale: Not at all (1) A little bit (2) Moderately(3) Quite a bit(4) Extremely(5)
Repeated, disturbing memories, thoughts or images of a stressful military experience form the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Relapsed, disturbing dreams of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling very upset when something reminded you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Avoid thinking about or talking about a stressful military experience from the past or avoid having feelings related to it?
Not at all
1
2
3
4
5
Extremely
Clear selection
Avoid activities or situations because they remind you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Trouble remembering important parts of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Loss of interest in things that you used to enjoy?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling distant or cut off from other people
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling as if your future will somehow be cut short?
Not at all
1
2
3
4
5
Extremely
Clear selection
Trouble falling or staying asleep?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling irritable or having angry outbursts?
Not at all
1
2
3
4
5
Extremely
Clear selection
Having difficulty concentrating?
Not at all
1
2
3
4
5
Extremely
Clear selection
Being “super alert” or watchful on guard?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling jumpy or easily startled?
Not at all
1
2
3
4
5
Extremely
Clear selection
A copy of your responses will be emailed to the address you provided.
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