Participant Information Form

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Personal Information

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

Medical Information

2. Are you taking any supplements?

Supplement Information

3. Do you have any chronic illness?

Chronic Illnesses

4. Do you have any current medical conditions?

Current Medical Conditions

5. Do you have any fears or phobias?

6. Do you or have you in the past suffered from a psychological disorder?

Medical Information

7. Are you currently taking any medication for any psychiatric disorder?

8. Have you experienced seizures or been diagnosed with epilepsy?

If yes, are you on medication?

9. Do you use stimulants and/or drugs?

Drug/Stimulant Information

10. Do you drink alcohol?

11. Do you have a drug or alcohol addiction?

12. Have you had an operation or surgery of any kind recently?

Surgery Information

13. Do you have a cardiovascular problem?

14. Is there anything about your physical/mental state I should know about?

15. Do you have previous experience working with Kambo medicine?

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.


905 – 304 – 9515

114 Munro Circle
Brantford, ON Canada – ​N3T OR4

905 – 304 – 9515