Physical Health Questionnaire - page 1

Vipassana Meditation as taught by S.N. Goenka

www.dhamma.org
CONFIDENTIAL MEDICAL HEALTH QUESTIONNAIRE
Name: _____________________________________ Course Dates:
_____________________
Please provide the following information, including all relevant details.
1. Physical health problems, past and present (Please list, giving full details of diagnosis, dates of
treatments, hospitalization, medication, etc.):
2. Prescription and/or non-prescription drug usage, past and present (Please list, giving full
details of dates, dosage and frequency):
3. Alcohol and/or drug use, past and present (Please list, giving full details of dates, frequency,
amounts used, any addictions and treatments):
4. Are you presently under a doctors or a therapists care for any of the above? No ___ Yes ___
If yes, please give details.
Signature Print your name here Date
Thank you for taking the time to provide us with this valuable information in the interest
of your safety.
Who would be available to help you in case of emergency during the ten-day course?
Name:
Telephone number/s:
His/her relationship to you:
Name:
Telephone number/s:
His/her relationship to you:
Physical Health Questionnaire - page 2
Vipassana Meditation as taught by S.N. Goenka
www.dhamma.org
Terms and Conditions of Admission to a Vipassana Meditation Course
PLEASE READ AND SIGN THE FOLLOWING STATEMENTS:
All students must stay at the course site following the rules and regulations for the duration of
the entire ten-day course unless given specific permission by the teacher to leave.
The prospective student of this technique of Vipassana meditation should understand the
seriousness of the course. Vipassana aims to purify the mind of deep-seated impurities such as
fear, anger, greed, aversion, etc. by bringing the mind into a state of perfect balance whereby
these impurities are objectively observed and uprooted. Thus it is necessary that a prospective
student be reasonably healthy both physically and mentally. Persons who have a previous history
of a severe mental or physical disorder should not attempt the course without the prior advice
and consultation of their physician and / or psychiatrist to ensure that they are indeed fit to
undergo this training.
By completing the application to participate in a ten-day Vipassana meditation course, the
applicant acknowledges the foregoing warning and in consideration of being permitted to
participate in the course knowingly grants to the organizers of this course, the Sayagyi U Ba
Khin Vipassana Trust and its associated organizations including Vipassana Center and teachers,
a complete, total and unequivocal release of any and all liability for any adverse mental or
physical consequences which may result directly or indirectly from such participation.
Signature Print your name here
Date
Thank you for taking the time to provide us with this valuable information in the interest of your
safety.
Please return the completed forms to the course registrar by email, fax, or mail. Please
return them as soon as possible, and feel free to contact us with any questions.
Sincerely,
The Registration Committee
Illinois Vipassana Meditation Center
10076 Fish Hatchery Road
Pecatonica, IL 61063
Tel. [1] 815 489-0420
Fax [1] (360) 283-7068
www.pakasa.dhamma.org