Ecstatic Mysticism Medical Information Questionnaire

What is your full name?* This field is required.

First Name

Last Name

What is your relationship status?* This field is required.single, married with children, married, widowed, separated or divorced, other

Please click if you have any of the following:* This field is required.

Diabetes

Allergies

High blood pressure

Low blood pressure

Asthma

Epilepsy

Recent surgery

Recent injuries eg: fractures or dislocations

Cardiovascular disease, including heart attack

Glaucoma

Displaced retina

Osteoporosis

Infectious or contagious disease

None of the above

If you clicked 'yes' to any of the above, please explain more about the condition(s).If it doesn't apply to you, please write N/A

Do you have a history of, or do you currently have, any medical conditions that were not listed in the above question? If yes, please explain.* This field is required.

Are you currently taking any prescription or non-prescription medications, substances or drugs? Please include medication name, frequency, and dosage.* This field is required.

Have you ever been to a psychologist or psychiatrist for any mental health issue or crisis? If so, please describe the situation.* This field is required.Eg: anxiety, depression, post-traumatic stress disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, panic attacks, insomnia, self-harming or attempted suicide, schizophrenia or psychotic episode, bipolar disorder, personality disorder, eating disorders etc.

Has there been a history of psychosis, mood disorders, or other severe mental illness in your family?* This field is required.

Have you ever been hospitalized for medical or psychiatric reasons in your life? If so, please elaborate.* This field is required.

Have you ever taken, or are you currently taking, antidepressants, antipsychotics, or benzodiazepines?* This field is required.

Do you have a history of alcohol or substance use addiction? If so, please describe which substances and how long you used for.* This field is required.

Are you pregnant?* This field is required.

YESNO

Are there any major sources of stress in your life at the moment, or any symptoms that you are experiencing which are impacting your health and well-being?* This field is required.

Do you currently have a therapist, mentor, or support group? Please describe.* This field is required.

Is there anything else that you would like to share about your physical and emotional health and well-being?* This field is required.

Emergency contact #1* This field is required.Name and relationship to you

Emergency contact #1 phone number and email* This field is required.

Emergency contact #2* This field is required.Name and relationship to you

Emergency contact #2 phone number and email* This field is required.

I declare that I have read and understood the above information and have answered all the questions completely and truthfully, and have not withheld any significant information regarding my mental health history, my physical health, and my psycho-emotional well-being. As of the moment that I submit this form, I commit to disclose to the the AWE staff of any change in my health status and of any inclusion or suspension of any medication (with or without medical prescription).* This field is required.

Ecstatic Mysticism Medical Information Questionnaire