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  • Personal History Questionnaire

    Whitebear Biometrics
  • Please note: The following questions are personal. Anything you share will be treated with the utmost ethical and professional confidentiality. Because this is an internet-based portal, you may choose to share some of your responses with me when we review this questionnaire and discuss your biofeedback goals.

    An effective and efficient biofeedback training program requires a comprehensive understanding of your individual patterns of stress responding.

    Please allow 35 to 50 minutes to complete this questionnaire. 

  • Section 1 of 10 Consent

    After you've read the terms of consent, indicate your level of agreement and your name into the field provided.
  • Cali Anicha, founder of Whitebear Biometrics, offers consultation and coaching using biofeedback instruments to support the development of skills that reinforce clear flexible thinking, as well as physical ease and wellbeing. Cali is a licensed teacher, has MS degrees in Special Education and Experimental Psychology, a PhD in Institutional Analysis, and is a certified Quantitative Electroencephalographic Technician (QEEGT). Cali is certified in Neurofeedback by the Biofeedback Certification International Alliance (BCIA-BCN) and is a Senior Fellow of that organization. She is a member of the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR). Cali adheres to the ethical principles and guidelines of these organizations.

    Biofeedback instruments improve your awareness of your physiologic status (such as heart rate, muscle tension, or brain wave activity) in real time, offering you the information needed to influence that activity moment-to moment – until you learn to do so without instrumentation.

    Biofeedback training is a process of providing information to you/the trainee about physical, nervous system, and brainwave activity. Sensors may be attached to your fingers, jaw, forehead or shoulders, earlobes, around your waist, and/or head to gather information. Nothing is done to the trainee. The sensors simply measure changes in the body systems monitored. The information is seen on a computer screen and/or heard through speakers or headphones. The trainee is able to see and hear changes in this physiological activity and, by practicing self-regulation techniques such as relaxation and breathing, the trainee can learn to produce changes in the systems being monitored. This process is expected to result in improvement in the trainee’s self-awareness and ability to cultivate and practice healthy responses to daily stressors.

    Research has been conducted to study the effectiveness of biofeedback and these studies have been published in peer reviewed, professional journals relevant to this field of study. Numerous studies have demonstrated the effectiveness of biofeedback interventions for a wide range of well-being and performance goals.

    In order to determine which biofeedback training tools may best fit your goals, a first step is to obtain baseline measures regarding your current mental/cognitive and physical responses to various tasks or stressors. This information is integrated with your own goals and scheduling options to construct a biofeedback training plan.

    Payment is due at the time of service and receipts are available upon request. Whitebear Biometrics does not provide mental nor medical health service and thus is not a contract provider for any health insurance plan or HMO.

    Because biofeedback is a learning process, repeated practice is needed to reach your self-regulation or well-being goals. Typical training periods range from 2-4 months of biweekly biofeedback sessions. Your learning rate can be enhanced by home practices which will be recommended depending upon your personal goals and schedules.

    These interventions are considered particularly safe and are generally without harmful side effects. However, any intervention that can lead to positive results can also lead to unwanted effects. Because this is a training approach, both desirable and undesirable effects continue for only a short time unless they are reinforced. This characteristic helps limit the potential for lasting negative effects and allows for the selective reinforcement of positive effects. Therefore, it is essential that you report accurately about your experiences during and following each training session.

    Cali provides these services on the basis of her experience working in a variety of biofeedback program settings, regular reviews of current research literature, and thorough ongoing professional development and continuing education. Whitebear Biometrics makes no claim or guarantee that biofeedback training will be effective for your specific goals.

    Trainees have the right to meaningful information about any assessment by this practitioner and the recommended course of training, including how long it is expected to take. Please ask any questions needed for you to be clear about biofeedback principles, instruments, or training sessions and expectations. Trainees may expect courteous and professional treatment by this practitioner. All trainee records and transactions are confidential unless release of these records is authorized in writing by the trainee, or otherwise required by law. Trainees will have access to their records.  Other services may also be effective for a trainee’s goals or concerns. Information about such services will be provided upon request to the extent possible.

    Trainees have the right to choose freely among available practitioners, and to change practitioners after services have begun. The trainee can expect a coordinated transfer if they change service providers.

    Trainees may refuse any service or training approach. Trainees may freely assert any of these rights.

    Complaints about this practitioner may be made to Better Business Bureau of Minnesota and North Dakota.

  • Section 2 - Contact Information

  • Section 3 - What do you hope to gain from biofeedback training?

  • Section 4 - Habits and Daily Life

  • Section 5 - Developmental Health History (birth-18yo)

    Please describe health details related to the developmental stage from birth to 18 years for questions 7 to 8.
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  • Section 6 - Health Status

    Please provide details of ANY major or minor injury occurring at any time in your life that may have impacted your head/brain, such as sports or accident related events.
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  • Psychological Stress and Life Changes

    Please provide details related to psychological stress and life changes.
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  • Major or Minor Injuries

    Please provide details of any major or minor injury occurring at any time in your life that may have impacted your head/brain, such as sports or accident related events. Please state the approximate date(s), location of impact, severity, immediate symptoms, lasting symptoms, evaluations, x-ray, repeated injuries, etc.
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  • Section 7 - Signs of Stress Checklist

    Please indicate if you have a history, are currently experiencing, or if any of the following stressors are currently bothersome:
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  • Section 8 - Sleep Quality

    For each question, choose the answer that best describes how you have felt and how things have been going for you during the PAST MONTH.
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  • Section 9 - General Well-Being Scale

    For each question, choose the answer that best describes how you have felt and how things have been going for you during the PAST MONTH.
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  • Section 10 - Breathing Habits

    The following checklists have been designed to serve as a guide for assisting you in exploring whether or not your breathing habits are consistent with optimal respiration.
  • How often do you experience any of the following symptoms:

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  • In what situations are you likely to experince or notice your breathing habits?

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  • Almost Complete!

    Use the back button to review your answers and statements. Once you are satisfied, click submit.
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