Fill out the form below to prepare for your appointment.

Personal Information

1. Are you currently taking any medication and what dosage?
YesNo
Medication Information

2. Are you taking any supplements?
YesNo
Supplement Information

3. Do you have any chronic illness?
YesNo
Chronic Illnesses

4. Do you have any current medical conditions?
YesNo
Current Medical Conditions

5. Do you have any fears or phobias?
YesNo
6. Do you or have you in the past suffered from a psychological disorder?
YesNo
7. Are you currently taking any medication for any psychiatric disorder?
YesNo
Medication Information

8. Have you experienced seizures or been diagnosed with epilepsy?
YesNo
If yes, are you on medication?

9. Do you use stimulants and/or drugs?
YesNo
Drug/Stimulant Information

10. Do you drink alcohol?
YesNo

11. Do you have a drug or alcohol addiction?
YesNo
12. Have you had an operation or surgery of any kind recently?
YesNo
Surgery Information

13. Do you have a cardiovascular problem?
YesNo
14. Is there anything about your physical/mental state I should know about?
YesNo
15. Do you have previous experience working with Kambo medicine?
YesNo
Previous Experiences

Kambo cannot safely be used if you have ever any of the following health conditions:

  • If you have a heart conditions
  • If you have had a stroke
  • If you are on medication for low blood pressure
  • If you have had a brain hemorrhage
  • If you have had an aneurism
  • If you have had a blood clot
  • If you have a serious mental health problem
  • If you are currently undergoing chemotherapy or for 6 weeks afterwards
  • If you take immune-suppressant medication for an organ transplant
  • If you have had an organ transplant
  • If you are pregnant
  • If you are breastfeeding a child under 6 months of age
  • If you have eaten within 12 hours prior to treatment
  • If you have had any water based detox within 3 days prior to your kambo treatment (for example: colonics, enemas, liver flushes)

I hereby certify that I have accurately and truthfully completed the above Participant Form and read
the contraindications.