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. Please leave this field empty.