MEDICAL FORM:

             For All Ayahuasca & Plant Medicine Retreats

Please Disclose Any And All Health Conditions That Have Been Diagnosed Or That You Feel You May Have, But Have Been Un-Diagnosed To Date. Being Transparent On This Form Is Essential To The Safety Of All Who Attend and work on Our Retreats. Thank You In Advance For Your Truth And Transparency. We Appreciate You.

Name *
Name
Medications *
Are you currently or have you in the last 90 Days taken any pharmaceutical medications?
As some pharmaceuticals may not be safe to be taken in union with ayahuasca or other plant medicines, we request & require full disclosure in this regard.
Have You Ever Been Diagnosed With A Potentially Life Threatening Ailment?
Do You Have A History Of Heart Conditions?
Have You Ever Experienced What You Might Call A Major Life Trauma?
near death experience, tragic death of a close relation, life threatening illness, serious addiction, physical/emotional/sexual abuse, military service in war time, etc...
Have You Ever Been Diagnosed With A Mental Imbalance Or Disorder? *
bipolar disorder, schizophrenia, manic depression, post traumatic stress disorder, etc...
Also state any undiagnosed mental health issues you may be facing.
Have You Ever Been Diagnosed With Chronic High Blood Pressure?
Have You Ever Been Diagnosed With Diabetes, Or Do You Think You May Be Struggling With The Symptoms Of Pre-Diabetes?
Are You Currently Experiencing Chronic Liver Problems?
Are You Experiencing The Symptoms Of Kidney Failure Or Malfunction?