Medical Questionnaire

First Name(s)

Last Name

Residing At

Your Email

Country

Your Phone No.

Gender
MaleFemale

Birth Date

Emergency Contact Person's Name & Relationship

Emergency Contact Person's Phone

Dietary Preference

Special Dietary Requirements/Food Allergies:

How did you hear about us?

Have you taken Ayahuasca before?
YesNo

If yes, How many times?

Have you experienced adverse or particularly difficult experiences with ayahuasca that you have found hard to integrate?

Do you have a past history of, or currently suffer from any serious health conditions? Give details

Are you currently pregnant or breastfeeding?
YesNo

Have you ever been pregnant?
YesNo

Have you ever terminated a pregnancy? Voluntarily or Involuntarily?

Have you ever been hospitalized for medical reasons or had any surgeries? (If yes, please describe)

Have you ever broken any bones? (If yes, please describe)

Do you have any gastric issues? (If yes, please describe)

Do you have any heart or blood pressure issues? (If yes, please describe)

Do you suffer from any heart conditions? (If yes, please describe)

Do you suffer from any lung or repository problems? (If yes, please describe)

Do you suffer from diabetes?

Do you suffer from epilepsy?

Do you suffer from any liver or kidney problems?

Are you currently taking any type of medications? If yes, please list the medications dosage and frequency taken. (Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous.)

Do you have any history of depression, anxiety, addictions or PTSD? (Please note that ceremonies should not be seen as nor are they designed as a substitute for psychiatric or other medical care.)

Do you have any history of psychosis, bipolar illness, personality disorder or schizophrenia?

Have you ever taken SSRI medication for depression? If so when? For how long?

Have you ever been hospitalized for psychiatric reasons? (If yes, please describe)

List any medications that you have taken in the past 12 months, prescribed or over the counter. (Please include dosage and frequency taken.)

List any recreational substances that you have taken over the past 12 months. (Including alcohol and marijuana)

What is your purpose for drinking Ayahuasca?

Have you suffered from any past emotional trauma that we should know about? Please give details.

Additional Information you would like the Shaman to know:

All information that you give us below is treated in the strictest confidence, please do not withold any information as your safety is paramount.