Kambo Medical History

  • Medical History Questionnaire for Kambo Treatment

  • Kambo treatments are a very safe affair when performed by a qualified practitioner. 

    However, there are scenarios where Kambo is contraindicated. Please complete this questionnaire to the best of your knowledge.

    The answers are for your own safety and help me to identify risks and tailor the treatment to your needs.

    All data are covered by privacy and copyright.

  • Format: (000) 000-0000.
  • 1. Are you currently on medication?*
  • 2. Do you suffer from chronic disease?*
  • 3.Are you suffering from an acute illness?*
  • 4. Do you suffer from fears or phobias?*
  • 5. Do you suffer from mental health problems or has this been an issue in the past?*
  • 6.Have you had seizures in the past or have you been diagnosed with epilepsy?*
  • 7. Do you use stimulants and/or drugs?*
  • 8. Do you drink alcohol?*
  • 9.Have you ever had to fight an addiction? Important: Addictions are not limited to drugs and alcohol.*
  • 10.Have you had any surgery or major surgery lately?*
  • 11.Have you ever had or do you still have any heart disease?*
  • 12.Have you ever had a stroke or a cerebral hemorrhage?*
  • 13.Have you ever had an aneurysm or a blood clot?*
  • 14.Have you had an organ transplant or need to suppress your immuneresponse for any other reason?*
  • 15.How would you describe your blood pressure?*
  • 16.If you checked "rather low": Are you taking medication to increase or maintain your blood pressure?*
  • 17.Have you undergone chemotherapy or radiotherapy in the last four weeks?*
  • 18.Are you pregnant, about to have your next period, or are you nursing a child less than 6 months old?*
  • 21.Did you take Iboga or Bufo in the last 6 weeks?*
  • 22. Do you suffer from panic attacks?*
  • 23.Have you fasted on food or water in the last seven days?*
  • 24.Have you had your Covid vaccine recently?*
  • 26. Do you do sport regularly?*
  • 27. Did you ever fainted?*
  • 28. How many ceremonies would you like to do?*

  • The data in the questionnaire is collected in accordance with the statutory data protection regulations and treated with absolute condentiality.

    I declare and understand:

    - The IAKP practitioners are not doctors, nor any other form of medical professionals.

    - That IAKP practitioners do not diagnose diseases, treat mental health problems and do not prescribe medication or pharmaceuticals.

    - That any treatment I receive is not a substitute for medical or psychological diagnosis or treatment from a qualified healthcare professional.

    - That it is recommended that I see a doctor for any physical or psychological problem I have now or in the future.

    I hereby release Alessandra Sparano from any liability resulting from the use of materials, preparations, remedies or treatments and assume full liability
    and responsibility for all risks related to this treatment.

    I confirm that I fully understand the content of this document.

    Hereby I declare the correctness of my data.

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