Grof Legacy Training Canada Medical Form Please enable JavaScript in your browser to complete this form.General Medical History Do you have a past history of, have you been diagnosed with, or are you currently experiencing any of the following: *Cardiovascular disease, heart attacks, arteriosclerosis, cardiovascular surgery, angina pectoris, aneurysm, arrhythmiaHigh blood pressureStrokes, TIAs, seizures, or other brain or neurological conditionsDiagnosed psychiatric conditionRecent surgeryPast or recent physical injuries, including fractures or dislocationsPresent or current infectious or communicable diseasesGlaucomaRetinal detachmentEpilepsy (grand mal)OsteoporosisAsthma (if yes, please bring your inhaler to the workshop)None of the aboveAre you currently pregnant? *YesNoHave you been hospitalized in the past 20 years for significant medical issue(s)? *YesNoPlease describe issue(s)Are you currently taking any type of medication? *YesNo Please list all medications here:Please consider listing natural supplements as well.Is there anything else about your physical condition we should be aware of? *YesNoPlease describe.Injuries, physical limitations, allergies, etc.Psychological/Psychiatric Status & Trauma History Were there complications during your birth or during your mother's pregnancy? *YesNoPlease describe those complications.Are you currently in therapy or involved in any type of support group? *YesNoPlease describe.With approximate start dates and reason for therapy or support group.Have you had previous psychological care or counselling? *YesNoPlease describe.Please give approximate years you were seeing someone (more or less e.g. Nov 2016 to Feb 2017), and the reason/nature for the consultation at the time.Have you ever been hospitalized for a psychiatric/psychological reason? *YesNoPlease give the date(s) and the reason(s) for hospitalization(s).Have you experienced trauma? *YesNoPlease describe. This could be from physical, sexual or emotional abuse or neglect, natural disasters, or other sources of trauma.Have you or are you experiencing times when it has been difficult to keep doing your normal daily activities? *YesNoPlease describe.Your Experience & Perpective Have you experienced Grof Breathwork or a form of breathwork that activates holotropic (non ordinary) states of consciousness before? *YesNoNumber of breathwork experiences01 - 56 - 1010 - 2020 or moreAside from breathwork, have you experienced non-ordinary states of consciousness before? *YesNoPlease describe those experiencesTypes of substance, age at the time, quantity taken, context or purpose for consumption. Were there challenging experiences? Did those experience have an influence on your life? Insights or difficulties identified. Have you attended other psychedelic trainings? Etc.Integration & Support System This work may lead to profound shifts in your life and it is ideal to have a framework of resources in place ahead of time to support you before, during and after sessions. Having support to help you integrate your experiences can help you get the most benefit from the work. Describe how you are supported in the work you are doing in the context of this training? *What friend, loved one, counsellor or other trusted person(s) do you speak with about this work? What are their disposition towards you in pursuing this work? What practices do you feel will be most beneficial in helping you to integrate your experiences into your life? *i.e. speaking with trusted persons, meditation, mindfulness, yoga, art, bodywork, journaling, time in nature, etc.What resources do you have access to for supporting your integration and how will you put them to use? *Contact info Name *FirstLastAge *Email *OccupationI hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good. I understand that by submitting this form, I consent to communications with Grof Legacy Training Canada staff regarding my submission. Signature *Clear SignatureDate *Submit
