Name* First Last DOB* MM slash DD slash YYYY PhoneEmail* Are you currently taking any medication?* Yes No MedicationDossageReason for MedicationAdd more add another medication MedicationDossageReason for MedicationAre you currently taking any supplements?* Yes No SupplementDossageReason for SupplementAdd more supplements add another Supplement SupplementDossageReason for SupplementDo you have any chronic illness? Yes No ConditionDurationPlease SpecifyAdd more Illnesses add another Illnesses ConditionDurationPlease SpecifyDo you have any current medical conditions?* Yes No ConditionDurationPlease SpecifyAdd more Condition add another Condition ConditionDurationPlease SpecifyHave you taken 5meo DMT (Bufo) in the past 6 weeks? Yes No Please SpecifyDo you or have you in the past suffered from a psychological disorder? Yes No Please SpecifyAre you currently taking any medication for any psychiatric disorder? Yes No MedicationDosageReason for medicationHave you experienced seizures or been diagnosed with epilepsy? Yes No MedicationDosageDo you use stimulants and/or drugs? Yes No TypeDosage / FrequencyReasonAdd more stimulant add another stimulant / drug TypeDosage / FrequencyReasonDo you drink alcohol? Yes No How often?Do you have a drug, alcohol or any other addiction? Yes No Please SpecifyHave you had an operation or surgery of any kind recently? Yes No Date MM slash DD slash YYYY Operation / SurgeryDo you have a cardiovascular problem? Yes No Please SpecifyIs there anything about your physical/mental state I should know about? Yes No Please SpecifyDo you have previous experience working with Kambo medicine? Yes No Date MM slash DD slash YYYY PointsDate MM slash DD slash YYYY PointsDate MM slash DD slash YYYY PointsDate MM slash DD slash YYYY PointsHave you ever had a stroke? Yes No Have you ever had a brain hemorrhage? Yes No Are you recovering from a major surgery? Yes No Have you ever had an injury or trauma to the Oesophagus/Esophagus Yes No Do you or have you ever had tumors or ulcers in the throat? Yes No Do you have a heart condition? Yes No Do you have Boerhaave’s Syndrome (spontaneous rupture of the esophagus)? Yes No In the past 7 days have you done any water fasting, colonics, liver flushes, sauna's or sweat lodges? Yes No CAPTCHA
