Medical History & Screening Form – Healing Presence Collective

Medical History

First Name

Last Name

Prefered Name / Nickname

Gender

Perferred Pronouns

Age

Phone no.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Marital Status

Married

Unmarried

other

Occupation

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Medical and Psychological History

Please answer as completely & honestly as possible. Please elaborate on any “Yes” answers and use additional notes if necessary at the end of this form. Your responses will remain strictly confidential.

Are you currently pregnant, breastfeeding, or in the process of trying to become pregnant?

Yes

Please specify and elaborate:

Do you take any Lithium, Tricyclic antidepressants on a regular basis?

Yes

Lithium, Tricyclic Antidepressant Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you take any Selective Serotonin Reuptake Inhibitors on a regular basis?

Yes

SSRI Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you take any Monoamine Oxidase Inhibitors on a regular basis?

Yes

MAOI Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you take any Steroids on a regular basis?

Yes

Steroid Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you take any Amphetamines on a regular basis?

Yes

Amphetamine Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you take any Narcotic Analgesics on a regular basis?

Yes

Narcotic Analgesic Medication

Medication	Condition	Dose	Frequency	Experienced Side Effects

Do you use any “over the counter” Antidepressants?

Yes

“over the counter” Antidepressants

Medication	Dose	Frequency	Experienced Side Effects

List any supplements (herbs or vitamins) you have taken regularly or semi-regularly in the past 3 months:

Have you ever had a panic attack?

Yes

Please specify and elaborate:

Have you been in counseling with a psychiatrist, psychologist, or other counselor within the past two years?

Yes

Please briefly specify reason for counseling & with whom:

Have you ever been hospitalized for a psychological or emotional problem?

Yes

Please explain:

Have you ever had a seizure?

Yes

Please explain (frequency & duration):

Do you have any history of cardiovascular disease, heart failure, or stroke?

Yes

Please explain:

Do you have any food allergies?

Yes

Please explain

Do you have any allergies to medications?

Yes

Medication

Any recent or chronic communicable or infectious diseases?

Yes

Please explain

Do you have any other special physical or emotional conditions?

Yes

Please explain

Do you have asthma?

Yes

Please explain, plus medications used:

Do you have LOW blood pressure?

Yes

Please explain, plus medications used:

Medication	Dosage	Frequency

Do you have HIGH blood pressure?

Yes

Please explain, plus medications used:

Medication	Dosage	Frequency

Do you have hepatitis?

Yes

Please explain, plus medications used

Do you have diabetes?

Yes

Please explain, plus medications used

Do you have glaucoma?

Yes

Do you have any bone, joint, or muscle problems?

Yes

Please explain:

Any recent surgeries or physical injuries?

Yes

Please explain:

Do you drink alcohol?

Yes

Alcohol use

Number of drinks	Frequency

Do you use Cannabis?

Yes

Cannabis use

Amount used	Frequency

Additional notes

Certification and Agreement

I certify, warrant, and represent that the information provided above is a complete and accurate statement of the physical and psychological conditions that may affect my participation in HPC’ Spiritual Gatherings.

I realize that failure to disclose such information could result in serious harm to myself and others.

I agree to indemnify and hold harmless HPC if all relevant information is not disclosed.

I understand that HPC has a zero-tolerance policy for acts of sexual harassment, physical violence, or threats of physical violence during any of the Spiritual Gatherings.

I undertake full responsibility to notify HPC should there be any changes in my health status.

Signature

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