City, State, Zip
Your Custom Text Here
Emergency Contact Name
Emergency Contact Phone Number
What are your reasons for wishing to work with this medicine? Please be as specific as possible about your intentions for the retreat.
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 with liver enzymes over 4x normal levels
Pulmonary issues (issues with your lungs)
PMDD (Premenstrual Dysphoric Disorder)
Traumatic Brain Injury or head trauma
Crohn’s Disease or Irritable Bowel Syndrome
Active infections (ie. ulcers, pneumonia, or skin abscesses)
Blood-bourne disorders (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?
Have you ever been hospitalized with any serious medical issues, physical or psychiatric in nature (ie. head injury, suicide attempts, manic depression, etc.)? Please provide details and dates.
Please provide a list of all prescribed and non-prescribed pharmaecutical medications you are currently using or have used in the past 6 months.
Have you used any drugs within the last 30 days, and are you currently using drugs or think that you may use drugs immediately before or after the ceremony?
Please list any supplements, herbal medicine, hormones, and/or nootropics you are currently using or have used in the past 30 days.
Are you due to start any medications and/or supplements before, during, or immediately after ceremony?
Please list all medications to which you are allergic.
Do you drink alchohol? If so, please list the number of average drinks per week.
Have you used Kambo in the past 60 days? If so, when and how much?
Kambo is medicine that comes from a frog; it's typically applied via burns to the skin.
Have you ever suffered from severe trauma, family conflict, or abuse (sexual or physical)?
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 any food intolerances, allergies or dietary preferences?
Do you suffer from sleep disorders?
Do you suffer from 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?
Do you engage in any regular physical activity?
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?