Pre-Class Questionnaire for MBSR

Thank you for filling out these forms. I realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence. I 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. I will delete the form at the end of the course and other than contact information no record of any of your information will be kept.

Pre-Class Questionnaire for MBSR

Date MM / DD / YYYY

Name

Email Address

Phone #

Address

How Did You Hear About this Class

* If other Please specify

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

Occupation

Year of Birth

Gender Identity

Gender Pronouns

Family Information Family Information Single Married Living with Partner Not Living with Partner Separated Divorced Widowed Other

Do you have children? Do you have children? Yes * No

* If Yes, Ages?

Do you have close friends? Do you have close friends? Yes No

Do you have old, long-term friends? Do you have old, long-term friends? Yes No

Who is your closest emotional support?

Sleep-- Quality and Quantity

Do you smoke (cigarettes)? Do you smoke (cigarettes)? Yes * No

*If yes, how much do you smoke?

Number of caffeinated drinks per day

Do you exercise? Do you exercise? Yes No

Do you eat a balanced diet? Do you eat a balanced diet? Yes No

Do you currently use alcohol or recreational drugs? Do you currently use alcohol or recreational drugs? No Yes Alcohol* Yes- recreational drugs* Yes-- both*

*If you responded yes above please describe, how much, specific drugs, how often etc.

Any History of Addiction? Any History of Addiction? Yes * No

*If yes, please describe?

If you have any current significant medical problems, please describe

If you have any current significant psychological problems, please describe

Do you have a history of trauma? Do you have a history of trauma? Yes * No

*If yes are you actively experiencing symptoms that feel connected to this trauma? flashbacks, nightmares, having difficulty with attention etc. *If yes are you actively experiencing symptoms that feel connected to this trauma? flashbacks, nightmares, having difficulty with attention etc. Yes No

Are you currently in therapy? Are you currently in therapy? Yes * No

If yes, does your therapist know you are taking this course? If yes, does your therapist know you are taking this course? Yes No

Please list any medications you are currently taking.

What do you care most about?

What gives you the most pleasure in your life?

What current stressors are you facing?

Are there experiences you've had in the past that are still causing you stress? (If Yes, Describe in next question

Anything else you would like me to know?

List two or three goals you'd like to "achieve" as a result of your participation in this class?