Fill out the form below to prepare for your appointment. Personal Information 1. Are you currently taking any medication and what dosage? YesNoMedication Information 2. Are you taking any supplements? YesNoSupplement Information 3. Do you have any chronic illness? YesNoChronic Illnesses 4. Do you have any current medical conditions? YesNoCurrent 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? YesNoMedication Information 8. Have you experienced seizures or been diagnosed with epilepsy? YesNoIf yes, are you on medication? 9. Do you use stimulants and/or drugs? YesNoDrug/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? YesNoSurgery 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? YesNoPrevious Experiences Kambo cannot safely be used if you have ever any of the following health conditions:If you have a heart conditionsIf you have had a strokeIf you are on medication for low blood pressureIf you have had a brain hemorrhageIf you have had an aneurismIf you have had a blood clotIf you have a serious mental health problemIf you are currently undergoing chemotherapy or for 6 weeks afterwardsIf you take immune-suppressant medication for an organ transplantIf you have had an organ transplantIf you are pregnantIf you are breastfeeding a child under 6 months of ageIf you have eaten within 12 hours prior to treatmentIf 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. Please leave this field empty.