MBSR Questionnaire

Mindfulness-Based Stress Reduction Questionnaire

Thank you for filling out this questionnaire. I realize the personal nature of some of these questions. Please be assured that the completed forms are kept in strict confidence. I, Cory Muscara, am the only person who sees this information. Any information you are willing to provide will be of great help to me in assisting you with common issues that may arise. No record of this questionnaire, other than contact information, will be kept after the course is completed.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

How did you hear about this course? If you were referred by a health care provider, please provide his/her name. *

What is your main reason for participating in the Stress Reduction Program? *

Sleep Quality / Quantity: *

Do you Smoke? If Yes, how much? *

Caffeinated drinks per day: *

Do You Currently Use Drugs or Alcohol? If Yes, How Much? *

Any history of addiction? *

Any current significant medical problems? *

Any current significant psychological problems? *

Have you ever considered suicide? *

Do you have a history of trauma? *

Are you currently in Therapy? *

Yes No

Do you take Prescription Medications? (Please list) *

What are your greatest worries/stressors? *

Is there anything else you would like me to know? *

List 2 or 3 target goals you'd like to "achieve" as a result of your participation in the MBSR program: *

Informed Consent Agreement

The benefits and risks of the Mindfulness-Based Stress Reduction Program were explained to me in detail. This includes skill training in relaxation and meditation methods, as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises, either during the weekly sessions at Family Medicine Associates or at home, I am under no obligation to engage in these techniques nor will I hold the above named facility or its instructor liable for any injury incurred from these exercises.

By choosing "Yes," you agree to the above informed consent agreement. *

Yes

Submit