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Your safety is my primary goal

Before the ceremony takes place, it is important to read and discuss with me any medical conditions you have and/or medications, supplements, vitamins, and minerals you are currently taking or have taken in the past. At the same time, it is important to discuss if you have been drinking alcohol or using any type of drugs. It is also important for me to know if you have been participating in ancestral medicines like Bufo Alvarius, Iboga, etc. Your safety is my primary

goal.

Kambo sessions are safe if performed by an experienced and trained practitioner. However, there are cases where Kambo is contraindicated.

Kambo is not safe for the following people:

If you have serious heart problems.

If you have had a stroke.

If you are taking medication for low blood pressure.

If you have had a brain hemorrhage.

If you have had an aneurism or blood clots.

If you lack the mental capacity to make a decision to take Kambo.

If you have serious mental health problems (excluding depression, PTSD and anxiety).

If you are undergoing Chemotherapy, Radiotherapy (you would need to wait 6 weeks afterwards).

If you are taking immune suppressants for organ transplants.

If you are pregnant or you think you are.

If you are breast-feeding a child under 12 months old.

If you have Addison’s Disease.

If you have Ehler Danlos Syndrome.

If you have a history of multiple medical procedures involving the Esophagus. Eg. Endoscopy, seeing blood in the vomit, etc.

If you have current and severe Epilepsy.

If you are recovering from a major surgery.

If you are under 18 years old.

Please complete this questionnaire to the best of your ability. The answers are for your own

safety and would help me to identify potential risks and tailor the sessions to your needs.

Full Name *

Phone *

Email *

Emergency Contact Name *

Emergency Contact Number *

Address

Street Address

Are you currently taking any medication, vitamins, minerals or supplements? *

Yes

No

Please indicate the name of All of them, when you started taking them, dosage and how often: *

Do you suffer from chronic diseases? *

Yes

No

Please indicate the name, current symptoms, how do you feel at the moment? What has been the treatment? *

Are you suffering from an acute illness? *

Yes

No

Please indicate the name or symptoms, when you started experiencing them, how do you feel at the moment and what has been the treatment so far? *

Do you suffer from fears or phobias? *

Yes

No

Which ones? What effects do they have on you? *

Do you suffer from any mental health problems or has this been an issue in the past? *

Yes

No

Please explain. Has a medical diagnosis been made? Are you currently taking any medication and/or supplements for that? (indicate name, dosage). *

Have you had any seizures in the past or have you been diagnosed with epilepsy? *

Yes

No

Please explain seizures or epilepsy *

Do you use any stimulants and/or drugs? *

Yes

No

Please indicate which ones, the amount and how often. *

Do you drink alcohol? *

Yes

No

Please explain. How often? How many drinks? How do you rate your drinking habits? *

Do you suffer from bulimia? Is there any other reason you may suspect your esophagus and stomach could be weakened? *

Yes

No

Please provide more information *

Have you ever struggled with addiction? Important addictions are not limited to drugs and alcohol. *

Yes

No

Please provide more information on your addiction *

Have you had any major surgery in the past 3 months? *

Yes

No

Please explain the surgery *

Have you ever had, or currently have, any heart problems? *

Yes

No

Please input

Please explain the heart problem? *

Have you ever had a stroke, hemorrhage or any serious physical trauma in your head? *

Yes

No

Please explain stroke, hemorrhage or any serious physical trauma in your head?

Have you ever had an aneurism or blood clot? *

Yes

No

Please explain aneurism or blood clot?

Have you had an organ transplant or need to take an immune suppressant medication for any reason? *

Yes

No

Please explain organ transplant or need to take an immune suppressant medication for any reason? *

How would you describe your blood pressure? *

Normal

High

Low

If low or high, are you currently taking any medication? Which ones and dosage?

Have you received chemotherapy or radiotherapy in the last 6 weeks? *

Yes

No

Are you pregnant, about to have your next period, or are you nursing a child less than 1 year old? *

I am pregnant

I believe I might be pregnant

I am about to have my period or already have it

I am breast feeding

None of the above

Did you get vaccinated for COVID-19? *

Yes

No

How long ago was the last vaccination (or booster) you got? Did you get any side effects? Have you had difficulty getting fully recovered after infection, with or without vaccination? *

Would you like to tell me anything else about your health that was not covered by the questions?

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