Medical Health Screening Application Name * First Name Last Name Checkbox * Which offering is this for? Private Kambo Ceremony Private Bufo Ceremony Bufo Practitioner Training Medicine Retreat What is your gender? * Email * What's your phone number? * (###) ### #### Emergency Contact: * Who referred you? * Do you have any experience with plant medicine? (If so please share which ones and how often you take them.) * Do you take any recreational substances including drugs and/or alcohol? If so please share which ones and how often. * Do you have a history of substance abuse? If so please explain. * Are you taking any other drugs like caffeine, pain killers or allergy medications? * Are you on any prescription medications? If so which ones and what dosage are you taking/ how often? * Do you have any history with mental illness? If so pease describe. * Do you have a history of PTSD or suffer from acute trauma? If so please explain. * Do you struggle with addictions, depression or anxiety? Please explain. * Do you have any of the following: High blood pressure, low blood pressure, cardiovascular issues, liver & kidney, head injuries, history of seizures, respiratory issues or drug allergies? * Do you have a history of hypertension (higher blood pressure)? Do you know your most recent vital signs including blood pressure, heart rate, oxygen saturation? (If not we will assess during your first session). * Do you have serious heart problems? Have you had heart surgery? This includes a pacemaker but excludes stents. * Have you had a stroke or a brain haemorrhage? * Have you had an aneurism or blood clot? * Are you recovering from a major surgical procedure with internal stitches? * Are you on medication for low blood pressure? * Are you undergoing chemotherapy, radiotherapy or have done so within the last 4 weeks? * Are you taking immune-suppressants after an organ transplant? * Do you have Addison’s Disease? * Do you have current and severe epilepsy? Are you on any medication for epilepsy? * Are you recovering from a major surgical procedure? * Do you have certain types of eating disorders? * Do you have Crohn’s Disease, IBS or any digestive issues? * Will you have been fasting at any point 7 days before or after your ceremony work? * Will you be able to not have any enemas, colonics, intensive sweating or liver flushes within 3 days before and after your ceremony work? You will be needing all of your electrolytes and it can be dangerous if you deplete them with these methods of detox. * Will you be menstruating at the time of your session? It can be uncomfortable to have Kambo during this time as the medicine can increase bleeding, cramping & lightheadedness. * Can you abstain from alcohol, marijuana and other recreational substances for at least 24-48 hours before your Kambo session? * Do you have any pre-existing medical conditions? If so please explain. * Have you been vaccinated with CV19 vaccine? If so, how many times and when? * Are you pregnant or breast feeding? Are you breast feeding a child under 6 months years old? * Do you have any of the following: schizophrenia, schizophrenic tendencies, borderline personality disorder, serotonin syndrome, bipolar disorder or suicidal tendencies? * Please share any major traumas that have happened in your life (including childhood traumas) and any therapies or treatments you have accessed. * Are you taking any of the following supplements: Kratom, mood stabilizing supplements, natural sleep aids, diet pills? Please explain and list all supplements you are taking under this category. * Do you have any dietary restrictions? * Please share about what is calling you to ceremony at this time. * What resources do you have in your life to support you? Example: Meditation practice, therapist, life coach ect. * Is there anything else that you wish to share? Do you have any further questions? * Thank you! We will review your health screening application and get back to you shortly.
