MEDICAL FORM:

                           For All Ayahuasca 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. The information you present here is confidential and will not be held up for judgement or shared with anyone outside of our small group of healers, in order to offer the highest level of care that we can to all of our guests. Thank You In Advance For Your Truth And Transparency. We Appreciate You.

Name *
Name
First & Last Name
please include month year of retreat, & also whether you wish to attend a retreat of 7, 10, 12, or 14-days.
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 with Ayahuasca or other plant medicines, we require full disclosure in this regard.
Have you ever been diagnosed with a life threatening illness? *
Do you have a history of heart conditions? *
Do you have a history of high or low blood pressure? *
Do you have a history of fainting in the last 5 years? *
Have you ever had what you might call a Major Life Trauma? *
near death experience, tragic death of a loved one, life threatening illness, serious addiction, physical, emotional sexual abuse, military service in wartime, incarceration, childhood abandonment, etc...
Have you ever been diagnosed with a Mental Imbalance or Disorder, or do you feel you may have an undiagnosed mental disorder? *
bi-polar disorder, schizophrenia, manic depression, post-traumatic stress disorder, etc...
Have you ever been diagnosed with type 1, type 2, or pre-diabetes? *
Do you feel you may have any major undiagnosed health conditions, that you think we should be aware of? *
Do you have a history of liver, kidney or gall bladder problems? *