Mindfulness-Based Stress Reduction:
Intake Registration Forms and Questionnaires (Baseline)
Please complete all the items on the following forms and
questionnaires, and bring them with you to the orientation.
Check-in by 12:40 pm at NYGH, 8th floor, Mental Health
Your kind attention to this process in a timely manner is greatly
appreciated.
Date __________
Contact Information - MBSR
Name ___________________________________ Birth date _______________
Telephone # :
Home ____________________ Work ___________________
Cell ____________________ Other ___________________
e-mail
________________________________________________________
Address
_________________________________________________________
_________________________________________________________
Health Card (OHIP) # _________________________ Version Code ___________
Expiry date _________________________________________________________
Referring doctor
Name:
Family doctor (if different)
_________________________ Name: ___________________________
Specialty: _________________________ Phone ___________________________
Phone #
Fax #
_____________________
Fax # ___________________________
____________________
The information from your responses to the following questionnaires may be
useful to you, and to us in monitoring your progress through the stress reduction
program. It might also be useful in helping us to improve the program for others.
For this reason, the information might be pooled and used for statistical research
purposes. You will NOT be identifiable as an individual in any of the analyses,
nor in any publications that result from it. Please sign under your choice:
□ yes, I agree my information can be used
□ no, I do not want my information to be used
_______________________________
_________________________________
Date _________
ID # ________
MBSR Intake Information and Questionnaires
Thank you for filling out these forms. Please answer all the questions.
We realize the personal nature of these questions. Please be assured
that the completed forms are kept in strict confidence.
1) Gender: (please circle)
Male
Female
2) Weight: _________________________ Height _______________________
3) Occupation (past or present) ___________________________________________
Currently working ____ Unemployed ____ Sick leave / LTD _____ Retired ____
4) Education (highest level completed): High school _______ College _______
University Bachelor’s degree ______ Master’s degree _______ PhD __________
Other Professional (eg. MD, DDS, DVM, LLB, etc.) _______________________
5) Ethnic background: ________________________________________________
6) Relationship status: (please circle)
single
married
common law
7) Do you have any children?
separated
divorced
widowed
No___ Yes ___ their ages: ___________________
8) Please list ALL your health problems / diagnosis Medical: _____________________________________________________________
____________________________________________________________________
Psychological: ________________________________________________________
_____________________________________________________________________
9) Do you currently take any medication? No __ Yes __ (please list ALL, with dosage):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
(please indicate with an asterisk * those which you just started within the past 2 months)
10) Do you have a history of substance abuse / addiction? No __ Yes __
If yes, please explain: ___________________________________________________
_____________________________________________________________________
current use per week: alcohol (type) _______________ # glasses/shots/pints ______
cigarettes (# of packs) ____ caffeine (# cups coffee + tea + chocolate + cola) ______
recreational drugs (type) __________ frequency per week ____________________
11) Are you currently getting some form of psychotherapy? No____ Yes_______
If yes, please describe reason/diagnosis: __________________________________
and type of therapy: group ____ individual _____ couples _____ family ______
frequency: more than once a week __ / once a week __ / every 2 weeks or less ___
psychiatric medication: ________________________________________________
12) Have you ever been in an MBSR course before? No __
13) Do you currently do yoga?
none ___ once or twice a month ___
Yes ___
date: _______
weekly ___
2-3/week___ daily ____
14) Do you currently practice meditation?
none ___ once or twice a month ___ weekly ___
2-3/week___ daily ____
15) Why has your doctor referred you / what is (are) the problem(s) that motivated you to
register for this program?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please identify 3 goals that you have for participating in this MBSR program:
1) ________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2) ________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3) ________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MBSR Informed Consent Agreement - North York General Hospital
The risks, benefits, and possible side-effects of the Stress Reduction Program were explained
to me. This includes skill training in relaxation and meditation methods as well as gentle
stretching (Hatha yoga) exercises. I understand that if for any reason I am unable to, or think
it unwise to engage in these techniques and exercises, either during the weekly sessions at the
NYGH or at home, I am under no obligation to engage in these techniques, nor will I hold the
above named facility or facilitator responsible for any injury incurred from these exercises.
Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions,
the full day session (6 hours on the 6th Saturday), and to practice the home assignments for
45 to 60 minutes per day, for the duration of the training program.
I also understand I am expected to notify the instructor at least 24 hours in advance (or with
as much advance notice as possible, given the circumstances) if for some unforeseeable
emergency, I am unable to attend any portion of a session.
I also understand that a Certificate of Completion will only be given to participants who have
attended at least 24/ 30 hours of the MBSR program.
_____________________
______________________________
Name (please print)
Signature
______________________
Witness
_______________________________
Date
MINDFUL ATTENTION AWARENESS SCALE
Below is a collection of statements about your everyday experience. Using the 1–6 scale
below, please indicate how frequently or infrequently you currently have each experience.
Please answer according to what really reflects your experience, rather than what you think
your experience should be.
1 - almost always
2 - very frequently
3 - somewhat frequently
4 - somewhat infrequently
5 - very infrequently
6 - almost never
1
almost
always
1
2
3
4
5
6
7
8
9
10
11
12
I could be experiencing some emotion and not be conscious of it
until some time later.
I break or spill things because of carelessness, not paying
attention, or thinking of something else.
I find it difficult to stay focused on what’s happening in the
present.
I tend to walk quickly to get where I’m going without paying
attention to what I experience along the way.
I tend not to notice feelings of physical tension or discomfort until
they really grab my attention.
I forget a person’s name almost as soon as I’ve been told it for the
first time.
It seems I am “running on automatic” without much awareness of
what I’m doing.
I rush through activities without being really attentive to them.
I get so focused on the goal I want to achieve that I lose touch
with what I am doing right now to get there.
I do jobs or tasks automatically, without being aware of what I’m
doing.
I find myself listening to someone with one ear, doing something
else at the same time.
I drive places on “automatic pilot” and then wonder why I went
there.
13
I find myself preoccupied with the future or the past.
14
I find myself doing things without paying attention.
15
I snack without being aware that I’m eating.
2
3
4
5
6
almost
never
PERCEIVED STRESS SCALE - 10 ITEM (PSS10)
Date _______________________
ID # ________
The questions in this scale ask you about your feelings and thoughts during the last week. In
each case, you will be asked to indicate how often you felt or thought a certain way. Although
some of the questions are similar, there are differences between them and you should treat
each one as a separate question. The best approach is to answer each question fairly quickly.
That is, don't try to count up the number of times you felt a particular way, but rather indicate the alternative
that seems like a reasonable estimate.
Never
Almost
Never
1. In the last month, how often have you been
upset because of something that happened
unexpectedly?
0
1
2
3
4
2. In the last month, how often have you felt
you were unable to control the important things
in your life?
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
7. In the last month, how often have you been
able to control irritations in your life?
0
1
2
3
4
8. In the last month, how often have you felt that
you were on top of things?
0
1
2
3
4
9. In the last month, how often have you been
angered because of things that happened that
were outside of your control?
0
1
2
3
4
10. In the last month, how often have you felt
difficulties were piling up so high that you
could not overcome them?
0
1
2
3
4
3. In the last month, how often have you felt
nervous and stressed?
4. In the last month, how often have you felt
confident about your ability to handle your
personal problems?
5. In the last month, how often have you felt that
things were going your way?
6. In the last month, how often have you found
that you could not cope with all the things you
had to do?
Some- Fairly
times Often
Very
Often
Beck Anxiety Inventory
Below is a list of common symptoms of anxiety. Please carefully read each item in the list.
Indicate how much you have been bothered by that symptom during the past month,
including today, by circling the number in the space in the column next to each symptom.
Item
Symptom
1
Numbness or tingling
0
Mildly,
but it
didn’t
bother me
1
2
Feeling hot
0
1
2
3
3
Wobbliness in legs
0
1
2
3
4
Unable to relax
0
1
2
3
5
Fear of worst happening
0
1
2
3
6
Dizzy or lightheaded
0
1
2
3
7
Heart pounding / racing
0
1
2
3
8
Unsteady
0
1
2
3
9
Terrified or afraid
0
1
2
3
10
Nervous
0
1
2
3
11
Feeling of choking
0
1
2
3
12
Hands trembling
0
1
2
3
13
Shaky / unsteady
0
1
2
3
14
Fear of losing control
0
1
2
3
15
Difficulty in breathing
0
1
2
3
16
Fear of dying
0
1
2
3
17
Scared
0
1
2
3
18
Indigestion
0
1
2
3
19
Faint / lightheaded
0
1
2
3
20
Face flushed
0
1
2
3
21
Hot / cold sweats
0
1
2
3
sums
total
Not at
all
Moderately it wasn't
pleasant at
times
2
Severely it bothered
me a lot
3
BECK DEPRESSION INVENTORY
INSTRUCTIONS: This questionnaire consists of 21 groups of statements. Please read each group
of statements carefully, and then pick out the one statement in each group that best describes the
way you have been feeling during the PAST TWO WEEKS, including today.
- Circle the number beside the statement you have picked.
- If several statements in the group seem to apply equally well, circle the highest number for that
group. Be sure that you do not choose more than one statement for any group, including Item 16
(Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).
1. Sadness
0 I do not feel sad.
1 I feel sad much of the time.
2 I feel sad all the time.
3 I am so sad or unhappy that I can't stand it.
6. Punishment Feelings
0 I don't feel I am being punished.
1 I feel I may be punished.
2 I expect to be punished.
3 I feel I am being punished.
2. Pessimism
7.
0 I am not discouraged about my future.
1 1 I feel more discouraged about my
future than I used to be.
2 I do not expect things to work out for me.
3 I feel my future is hopeless and will only get worse.
Self-Dislike
0 I feel the same about myself as ever.
1 I have lost confidence in myself.
2 I am disappointed in myself.
3 I dislike myself.
3.
Past Failure
0 I do not feel like a failure.
1 I have failed more than I should have.
2 As I look back, I see a lot of failures.
3 I feel I am a total failure as a person.
8. Self-Criticalness
0 I don't criticize or blame myself
any more than usual.
1 I am more critical of myself than I used to be.
2 I criticize myself for all of my faults.
3 I blame myself for everything bad that
happens.
4.
Loss of Pleasure
0 I get as much pleasure as I ever did
from the things I enjoy.
1 I don't enjoy things as much as I used to.
2 I get very little pleasure from the
things I used to enjoy.
3 I can't get any pleasure from the
things I used to enjoy.
9. Suicidal Thoughts or Wishes
0 I don't have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would
not carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
5.
Guilty Feelings
0 I don't feel particularly guilty
1 I feel guilty over many things I have
done or should have done.
2 I feel quite guilty most of the time.
3 I feel guilty all of the time.
10. Crying
0 I don't cry anymore than I used to.
1 I cry more than I used to.
2 I cry over every little thing.
3 I feel like crying, but I can't
Subtotal Page 1: ______
Continue to Page 2
11. Agitation
0 I am no more restless or wound up than usual.
1 I feel more restless or wound up than usual.
2 I am so restless or agitated that it's hard
to stay still.
3 I am so restless or agitated that I have to keep
moving or doing something.
17. Irritability
0 I am no more irritable than usual.
1 I feel more irritable than usual.
2 I am much more irritable than usual.
3 I am irritable all the time.
12.
Loss of Interest
0 I have not lost interest in other people or
activities.
1 I am less interested in other people or things
than before.
2 I have lost most of my interest in other people or
things
3 It's hard to get interested in anything.
18. Changes in Appetite
0 I have not experienced any change
in my appetite.
1 A-My appetite is somewhat less than usual.
B-My appetite is somewhat more than usual.
2 A-My appetite is much less than before.
B- My appetite is much greater than usual.
3 A- I have no appetite at all.
B- I crave food all the time.
13.
Indecisiveness
0 I make decisions about as well as ever.
1 I find it more difficult to make decisions
than usual.
2 I have much greater difficulty in making
decisions than I used to.
3 I have trouble making any decisions.
19. Concentration Difficulty
0 I can concentrate as well as ever.
1 I can't concentrate as well as usual.
2 It's hard to keep my mind on anything for
very long
3 I find I can't concentrate on anything.
14.
Worthlessness
0 I do not feel I am worthless.
1 I don't consider rnyself as worthwhile and
useful as I used to.
2 I feel more worthless as compared to other
people.
3 I feel utterly worthless.
20. Tiredness or Fatigue
0 I am no more tired or fatigued than usual.
1 I get more tired, or fatigued more easily
than usual.
2 I am too tired or fatigued to do a lot of the
things I used to do.
3 I am too tired or fatigued to do most of the
things I used to do.
15.
Loss of Energy
0 I have as much energy as ever.
1 I have less energy than I used to have.
2 I don't have enough energy to do very much.
3 I don't have enough energy to do anything.
21.
16. Changes in Sleeping Pattern
0 I have not experienced any change in my sleeping pattern.
1 A- I sleep somewhat more than usual.
B- I sleep somewhat less than usual.
2 A- I sleep a lot more than usual.
B- I sleep a lot less than usual.
3 A- I sleep most of the day.
B- I wake up 1-2 hours early and can't get back to sleep.
Loss of Interest in Sex
0 I have not noticed any recent change in my
interest in sex.
1 I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
Subtotal Page 2______
Subtotal Page1 ______
Total Score _________
MBSR – Pain Analogue Scales
Consider how you have felt over the past week.
1) Mark any area of consistent pain on the body diagrams,
then indicate (x) the intensity of that pain on the scale beside it.
for example:
migraines
1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
1
10
1
9
1
10
arthritis
1
0
1
1
1
2
1
3
no pain
1
0
1
4
1
5
1
6
1
7
1
8
unbearable,
excruciating pain
moderate pain
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
1
10
2) How often over the past week have you experienced this pain?
1
0
1
1
1
2
1
3
1
4
never
1
5
1
6
1
7
1
8
1
9
half of the time
1
10
constantly
3) How much suffering has this pain caused you ?
1
0
1
1
1
2
1
3
1
4
none
1
5
1
6
1
7
1
8
1
9
moderate
1
10
extreme,
unbearable
4) How much has this pain interfered with your daily life?
1
0
not at all
1
1
1
2
1
3
1
4
1
5
somewhat
1
6
1
7
1
8
1
9
1
10
a lot,
unable to function
SF-36 HEALTH SURVEY
This survey asks for your views about your health. This information will help keep
track of how you feel and how well you are able to do your usual activities.
Answer every question by marking the answer as indicated. If you are unsure about
how to answer a question, please give the best answer you can.
1. In general, would you say your health is:
(circle one)
Excellent ...........................................................................1
Very Good ........................................................................2
Good .................................................................................3
Fair ...................................................................................4
Poor ..................................................................................5
2. Compared to one year ago, how would you rate your health in general now?
(circle one)
Much better now, than one year ago ..........................................1
Somewhat better now, than one year ago ..................................2
About the same as one year ago ................................................3
Somewhat worse now, than one year ago .................................4
Much worse now, than one year ago .........................................5
3. The following items are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
ACTIVITIES
a. Vigorous activities, such as running, lifting
heavy objects, participating in strenuous
sports
b. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf
c. Lifting or carrying groceries
d. Climbing several flights of stairs
e. Climbing one flight of stairs
f. Bending, kneeling, or stooping
g. Walking more than a mile
h. Walking several blocks
Yes, Limited a Yes, Limited a
Lot
Little
No, Not
Limited at
All
1
2
3
1
2
3
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
i. Walking one block
1
2
3
j. Bathing or dressing yourself
1
2
3
4. During the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?
(circle one number on each line)
YES
NO
a. Cut down on the amount of time you spent on work or other activities
1
2
b. Accomplished less than you would like
1
2
c. Were limited in the kind of work or other activities
1
2
1
2
d. Had difficulty performing the work or other activities (for example, it took
extra effort)
5. During the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of any emotional problems (such as
feeling depressed or anxious)?
(circle one number on each line)
YES
NO
a. Cut down on the amount of time you spent on work or other activities
1
2
b. Accomplished less than you would like
1
2
c. Didn't do work or other activities as carefully as usual
1
2
6. During the past 4 weeks, to what extent has your physical health or emotional
problems interfered with your normal social activities with family, friends, neighbors,
or groups?
(circle one)
Not at all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Slightly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Moderately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Quite a bit , . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Extremely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7. How much bodily pain have you had during the past 4 weeks?
(circle one)
None ................................................................................................. 1
Very mild .......................................................................................... 2
Mild ................................................................................................... 3
Moderate ........................................................................................... 4
Severe ................................................................................................ 5
Very severe ....................................................................................... 6
8. During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home, and housework)?
(circle one)
Not at all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Slightly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Moderately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Quite a bit , . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Extremely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
9. These questions are about how you feel and how things have been with you during
the past 4 weeks. For each question, please give the one answer that comes closest to
the way you have been feeling.
How much of the time during the past 4 weeks .....
circle one number on each line
a. Did you feel full of pep?
b. Have you been a very nervous
person?
c. Have you felt so down in the
dumps that nothing could cheer
you up?
d. Have you felt calm and peaceful?
e. Did you have a lot of energy?
f. Have you felt downhearted and
blue?
g. Did you feel worn out?
h. Have you been a happy person?
i. Did you feel tired?
All of
the
Time
1
1
A Good
Most of Bit of Some of A Little
the
the
the
of the
Time
Time
Time
Time
2
3
4
5
2
3
4
5
None of
the Time
6
6
1
2
3
4
5
6
1
1
2
2
3
3
4
4
5
5
6
6
1
2
3
4
5
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
10. During the past 4 weeks, how much of the time has your physical health or
emotional problems interfered with your social activities (like visiting with friends,
relatives, etc)?
(circle one)
All of the time
Most of the time
Some of the time
A little of the time
None of the time
...................................1
...................................2
...................................3
...................................4
...................................5
11. How TRUE or FALSE is each of the following statements for you?
(circle one number on each line)
Definitely Mostly
Don't
Mostly Definitely
True
True
Know
False
False
1
2
3
4
5
b. I am as healthy as anybody I know
1
2
3
4
5
c. I expect my health to get worse
1
2
3
4
5
d. My health is excellent
1
2
3
4
5
a. I seem to get sick a little easier than
other people