MBSR Program Questionnaire Orientation Questionnaire Please complete the following questionnaire at least 48 hours before the Orientation Session. "*" indicates required fields CENTER FOR MINDFULNESS IN MEDICINE, HEALTH CARE, & SOCIETY™ MINDFULNESS-BASED STRESS REDUCTION PROGRAM Created by: UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOLDivision of Preventive & Behavioral Medicine Thank you, for filling out these forms. We realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence.Today's Date MM slash DD slash YYYY Name First Last Email* Home Telephone*Work TelephoneCell Telephone*Please indicate which phone number should be used to leave a message.Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands How did you hear about the program?*If it was from a health professional, could you offer the name and telephone number?”What is your main reason for participating in the Stress Reductions Program?*What is your occupation?*What is your date of birth?* MM slash DD slash YYYY Family Information*Please choose one. Single Married Not Married Living with Partner Separated Divorced Widowed Do you have children?* Yes No How Many Children?What are the ages of your children?Do you have close friends?* Yes No Sleep Quality*Do you smoke?* Yes No Caffeinated drinks per day:*Do you exercise?* Yes No How often?Do you use drugs or alcohol?* Yes No How much?Do you have a history of substance abuse?*Do you take prescription medications?(If possible, please list)Are you engaged in Psychotherapy?If no, have you been in therapy during the last three years?Previous overnight hospitalizations? – Medical/SurgicalPlease inform the yearPrevious overnight hospitalizations? – PsychologicalPlease inform the yearDuring the last MONTH have you:Considered suicide?* Yes No Sought psychiatric help?* Yes No Had thoughts of death or dying?* Yes No Had urges to beat, injure or harm someone?* Yes No Had urges to smash or break things?* Yes No Had spells of terror or panic?* Yes No Please take a moment as you respond to the following three questions. 1. What Do you care about the most?*2. What gives you the most pleasure in your life?*3. What are your greatest worries?*Any additional information you would like to provide to Irena and Rossana, your MBSR instructors? Things such as special arrangements for class, personal present struggles, or any other information you feel like sharing.*Please, indicate a person we could contact in case of an emergency:* First Last How is this person related to you?*Their phone number:*Their email address:* Please list three personal goals you have for taking the Mindfulness-Based Stress Reduction Program:*Please, what are the best days and times for you to receive a phone call from Irena Danys or from Rossana Magalhaes?*Consent*Mindfulness-Based Stress Reduction Program INFORMED CONSENT AGREEMENT The risks, benefits and possible side effects of the Mindfulness-Based Stress Reduction Program will be explained to me at the orientation meeting. This includes skill training in 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 or at home, I am under no obligation to engage in these techniques nor will I hold Irena Danys nor Rossana Magalhaes liable for any injury incurred from these exercises. Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions, the daylong session and to practice the home assignments for50-60 minutes per day during the duration of the training program. I consent to the above Informed Consent Agreement.Signature*Please type your name below – this is your signature.PhoneThis field is for validation purposes and should be left unchanged.