Phone Number (or What's App if outside of USA)
Emergency Contact Name
Emergency Contact Phone Number
Is your emergency contact aware that you will be embarking on this retreat?
What are your reasons for wishing to work with this medicine?
Do you currently have, or have you been diagnosed with any of the following medical conditions?
Heart conditions (ie heart murmurs, arrhythmia, palpitations, bradycardia or prolonged QT interval)
Cardiovascular disease, including heart attacks and any cardiovascular surgery
Hypertension (high blood pressure)
History of blood clots or coagulation abnormalities
Liver disease (Hepatitis, or liver enzymes over 4x normal levels?)
Pulmonary issues (Emphysema, etc.)
PMDD (Premenstrual Dysphoric Disorder)
Traumatic Brain Injury (past concussions, etc.)
Crohn’s Disease or Irritable Bowel Syndrome
Contagious diseases (strep throat, tuberculosis, giardiasis, etc)
Active infections (ie. ulcers, pneumonia, or skin abscesses)
Blood-bourne illnesses (ie. AIDS & HIV)
Psychiatric disorders (ie: bipolar, schizophrenia, psychosis, etc.)
If you answered YES to any of the above, please provide FULL details:
Do you have any other medical conditions or chronic illnesses not included on the list above?
Have you ever been hospitalized with any serious medical issues, physical or psychiatric in nature (ie. surgeries, head injury, suicide attempts, manic depression, etc.)? Please provide details and dates.
Please list all prescribed and non-prescribed pharmaecutical medications you are currently using or have used in the past 6 months.
Are you due to start any medications before, during, or immediately after ceremony?
Are you receiving treatment or taking medication that if discontinued may pose a health risk to yourself or others?
Will you be using any drugs (prescibed or non-prescribed) within 30 days before or after the ceremony?
Please list all medications to which you are allergic.
Please list any supplements, herbal medicine, hormones, and/or nootropics you plan to use within 30 days prior to the retreat.
Do you have any food intolerances, allergies or specific dietary needs?
Do you drink alcohol? If so, please list the average number of drinks per week.
Have you used Kambo in the past 30 days? If so, when and how much?
Kambo is an Amazonian frog medicine that is typically applied via burning to the skin and causes a strong purgative effect. It can be contraindicated with some of the medicines we use on our retreats.
Do you have any addictions (substance dependence or otherwise)? If so please provide details including dates and any medication or treatment taken.
Do you have a history of severe trauma, family conflict, or abuse (sexual or physical)?
Please let us know if have tried therapy or other modalities to address these issues. You can keep the details brief, and our facilitators will discuss this in more depth with you.
Do you have any sleep disorders?
Do you have any digestive problems (indigestion, constipation, diarrhea, vomiting, etc.)?
Please list any plant medicines that you currently use or have worked with in the past (including Iboga), and any difficulties that may have been encountered with these medicines.
Have you ever experienced altered states of consciousness, with or without psychoactive substances, spontaneous or induced?
Have you ever experienced a state of spiritual crisis or emergency? If so, please provide details including dates.
Do you engage in a regular spiritual practice? Do you practice any form of meditation?
Is there anything else about your physical or emotional status that we should be aware of?
Do you have a history of training or professionally competing in martial arts? If yes, please describe.
Please let us know any comments or questions that you might have.
To the best of your knowledge, are you in good health?
Have you answered these questions openly and honestly?
Thank you! A member of our team will be in touch with you.