MEDICAL INFORMATION
THE CLEAR WATER ZEN CENTER

Please answer the following questions in detail, using additional paper if necessary. The purpose of this medical information form is to help determine whether attendance at sesshin might adversely affect an applicant’s health. It also helps those conducting sesshin to be aware of physical and mental conditions that may require special consideration. For this reason it is vital that all information be current and specific in regard to both active and inactive conditions. This medical information is solely for the teacher’s and monitor’s reference and is not released to any other sesshin participant. Arrangements can be made if you need to speak privately with one of the teachers.

1. Briefly describe any medical or psychiatric conditions you have that require regular care or medication. ________________________________________________________

2. List any medications you are currently taking under a doctor’s prescription, and the reason for the use of each medication. _________________________________________

3. List any major surgeries you have had in the past five (5) years; also list any major organs that have been removed. ______________________________________________

4. List any hospitalizations or institutionalizations (for any reason, or for any length of time). __________________________________________________________________

5. Describe any significant problems you are having with your back, neck, or legs.
_______________________________________________________________________

6. Describe any other physical or mental conditions that may affect you or others in sesshin, such as pregnancy or menstrual problems, prostate problems, chronic headaches, or current illnesses. _______________________________________________________

7. Are you in psychotherapy at this time? ______________________________________

8. Describe any dietary considerations that might affect your sesshin, including all food allergies. ________________________________________________________________

9. Describe any other allergies (including allergic reaction to drugs). ________________

I agree to notify the teacher of any medical condition that may arise after submission of this Medical Information form and to file an updated form at such time.

Signature: ___________________________              Date: _________________________

Please print your name here:_________________________________________________