Medical History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cardiac disease
Diabetes
Psychiatric disorder
Epilepsy
Stroke
On medication for low blood pressure
Had a brain haemorrhage
Had chemo in the last 4-6 weeks
Addison’s disease
Aneurisms or blood clots
EDS
Current or severe epilepsy
Recovering from surgery
Have you had a covid vaccine
Other
Health conditions?
Do you have any medication allergies?
*
Yes
No
Not Sure
Check the symptoms that you're currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Neurological
Psychiatric
Gastrointestinal
Weight gain
Weight loss
Blood Clots
Are you currently taking any medication?
*
Yes
No
Please specify medications
Have you taken plant medicine In The past?
*
Yes
No
Date & which plant medicine?
Do you use or do you have history of using illegal drugs?
*
Yes
No
Please specify drugs & usage
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
By signing this you have been honest with your replies. I understand & agree to partake in the healing treatment. I am fully aware that kambô is uninsurable. Payments, Cancellations and Refunds. Ceremonies & healing treatments. A 50% deposit is required At the time of booking to reserve your space. By Bank Transfer or Cash if booking in person.Cancellations if you need to cancel please give as much notice as possible Cancellations with less than 48 hours notice - no refund will be given. If cancellation of event is made by me, a credit note will be issued.
What was the dates of your last covid vaccine?
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