• Kambo Medical Screening Questionnaire

  • Kambo can be a physically intense experience and, while it may be suitable for many people, there are circumstances in which it is contraindicated or requires particular caution.

    Please complete this questionnaire carefully and to the best of your knowledge. It is an important part of the preparation process and is required before participating in a Kambo session.

    Your answers help me assess potential risks, determine whether Kambo is appropriate for you, and adapt the session to your individual circumstances where possible.

    Please be open and thorough when providing information about your health, medical history, current conditions, and any medications or treatments you are taking.

    All data are covered by privacy and copyright.

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  • 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?*
  • 10.1 Have you ever had a previous oesophageal tear or rupture?"*
  • 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 six 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,Bufo or Ayahuasca in the last 6 weeks?*
  • 21.1. In the past two weeks, have you used any substances with therapeutic use or potential therapeutic applications, either under medical supervision or outside of a therapeutic context?*
  • 22. Do you suffer from panic attacks?*
  • 23. Have you ever suffered from Anorexia or Bulimia?*
  • 24. In the past 7 days, have you fasted from food or water, used enemas, undergone colon cleansing procedures, or performed any other bowel cleansing practices?*
  • 25.Have you had your Covid vaccine recently?*
  • 27. Do you do sport regularly?*
  • 28. Did you ever fainted?*
  • 29. How many ceremonies would you like to do?*

  • Declaration and Informed Consent


    The data contained in this questionnaire are collected and processed in accordance with applicable data protection laws and are treated with the strictest confidentiality.

    I declare that I have understood and agree to the following:

    • I understand that IAKP practitioners are not medical doctors or other licensed healthcare professionals.
    • I understand that IAKP practitioners do not provide medical diagnoses, diagnose or treat mental health conditions, or prescribe medications or other medicinal products.
    • I understand that any treatment or practice I receive does not replace medical diagnosis, treatment, or advice from a qualified doctor, psychologist, or other healthcare professional.
    • I have been advised to consult a doctor or qualified healthcare professional regarding any physical or psychological condition I may currently have or may develop in the future.

    I hereby confirm that I am responsible for the completeness and accuracy of the information provided in this questionnaire and that I have disclosed any health condition, medication, treatment, or other relevant information of which I am aware.

    I declare that I understand the nature, procedure, and potential risks associated with the treatment and accept responsibility for any consequences resulting from information that I have provided inaccurately, incompletely, or failed to disclose.

    To the fullest extent permitted by applicable law, I release Alessandra Sparano from liability arising from the use of any materials, preparations, remedies, or treatments provided as part of the session, except where such exclusion of liability is not legally permitted.

    I confirm that I have read and fully understood the contents of this document and have had the opportunity to ask questions and request clarification before the session.

    I further declare that all information and data provided by me in this questionnaire are accurate, complete, and truthful.

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