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Participant Information Form
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1. Are you currently taking any medication and what dosage?
2. Are you taking any supplements?
3. Do you have any chronic illness?
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?
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?
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?
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?
Kambo cannot safely be used if you have ever any of the following health conditions:
I hereby certify that I have accurately and truthfully completed the above Participant Form and read the contraindications.
114 Munro CircleBrantford, ON Canada – N3T OR4
905 – 304 – 9515
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