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Any Physical Disease Now or in the Past?
Physical Disease Details (dates, symptoms, duration,treatment, present condition)
Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?
Details of Mental Disease:(dates, symptoms, duration,hospitalization, treatment, present condition)
Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine,heroin, or other intoxicants)
Drug Use Details:dates, types, amounts,addictions, treatment, present use
Have you practiced any other meditation techniques (including other types of Vipassana), therapies or healing techniques(If you are an old studet,since your last course with S.N. Goenka or his assistant teachers)? [Combined Question for both new and old students]
Details of therapies or healing techniques:
Do you teach/practise these techiniques/therapies on others:
 
 
 
 
 
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