Medical Information Form

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    Do you have any physical disabilities or limitations due to injuries, disease, condition, surgery, or congenital conditions? If so please give all
    important details, dates, current condition, medications, and/or special requirements. *

    Do you have or have you ever had any serious disease? (For example: heart condition, asthma, epilepsy, cancer, stroke, rheumatic fever, TB, etc.) If so please give all important details, dates, current condition, medications, and/or special requirements. *

    Do you have any allergies? *

    Do you have any communicable diseases (e.g. HIV/AIDS, HEP-C, etc.)? Like all responses, this information will be kept completely confidential. *

    Are you currently seeing a psychotherapist, counsellor or psychologist? If so, when did you start going, and how often do you have sessions? *

    Are you now being treated or have you ever been treated for any mental or nervous condition, including, for example (but not limited to) nervous breakdown, psychosis (including drug-induced psychosis), chronic anxiety, insomnia, and sleeping disorders that required taking any form of medication and/or hospitalization? *

    Have you ever been diagnosed with any type of personality disorder? *

    Have you ever been a patient in a mental health care facility? If yes please give precise details and reason *

    Have you ever taken or are you currently taking: anti-depressants, anti-psychotics, sleeping pills, tranquilizers, or any prescribed medication which is commonly used for emotional illness, anxiety, or depression? Including, for example (but not limited to) Prozac, Xanax, Venlafaxine (Effexor XR), Chlorpromazine (Largactil), Haloperidol, Lithium, Mellaril or Stelaxine. (may also include other medications not listed here) If so, please give precise details. *

    Is there any history of mental illness, including severe depression, and/or history of taking medication for any nervous or mental condition in your immediate family? *

    Have you or anyone in your immediate family ever attempted or committed suicide? *

    Have you ever had or do you have any kind of food or eating disorder? *

    Have you recently used any drugs such as amphetamines, cocaine, barbiturates, ecstasy, hallucinogens (including ayuhasca, peyote, etc), marijuana, heroine, alcohol, etc? If so, when? Do you or have you had any problems with addiction to drugs including alcohol and/or tobacco? If so, please give details including quantities, frequency of consumption, and recovery program (if applicable). Please state any other addictions you feel are relevant. *

    Are you pregnant? If so, how many weeks are you now? *

    Do you have a reading or learning disability? *

    Have you ever been convicted or pled guilty to a crime involving violence? If so, please provide details. Is violent behavior an issue for you in general? *

    As we want you and the other participants to have a very good night's rest, we would like to know if you snore. If so we will try to arrange the right sleeping place for you and give the others a chance to sleep too. Thank you. *

    Is there anything else that relates to your physical, emotional or mental health that you would like us to know or would be helpful or important for us to know and that this questionnaire does not address? *


    By my signature, I represent that all the answers to this Medical Information Form are true and correct. I understand that any false statement is a ground without more for the termination of my participation in the program.

    Please Note: As this form will only submit if all fields have been filled out, please make sure you have completed them all. If a question does not apply, you can write "Does not apply".

    As this form will only submit if all fields have been filled out, please make sure you have completed them all. If a question does not apply, you can write "Does not apply".

    Please also ensure your photo is less than 2MB, or the form will not submit.

    Thank you!

    Keys To A New Life Team

    Signature

    (Please type your full name in the box): *

    If you are still having issues submitting this form please email info@keystoanewlife.com