KAMBO 11OUSE INTAKE

KAMBO 11OUSE

INTAKE FORM

Thank you for your interest in working with this beautiful treatment. The Spirit of Kambo is a profound way for you to cleanse, strengthen and energize your mind, body and soul. It’s a reset that allows you to return home to your highest self.

We are honored that you are here.
NAME*
ADDRESS*
PHONE*
EMAIL*
example@example.com
EMERGENCY CONTACT*
CONTACTS PHONE*
What are you hoping to get out of your experience with Kambo?
Please answer the following:
1. Are you currently taking any medication? If yes, please specify
2. Are you currently taking any supplements? If yes, please specify
3. Do you have any chronic illness? If yes, please specify
4. Do you have any current medical conditions? If yes, please specify
5. Are you allergic to tobacco or latex (if yes, please specify which)?
6. Do you, or have you in the past, suffered from a psychological disorder? If yes, then what type?
7. Are you currently taking any medication for any psychiotric disorder? If yes, please provide medicine & dose
Reason for medication
8. Have you experienced seizures or been diagnosed with epilepsy? If yes, are you on medication?
9. Do you use stimulants and/or drugs (includes marijuana)? If yes, then what kind? Frequency?
10. Do you drink alcohol? If yes, how often?
11. Do you hove a drug or alcohol addiction? Please specify.
12. Have you had an operation or surgery of any kind recently? If yes, what type of operation and when?
13. Do you have a cardiovasculor problem? Please specify.
14. Do you have any allergies? Please specify
16. What is your reason for taking this Kambo treatment?
17. Is there something about your physical or mental state that you think that I should know about? If yes, please specify.
18. Do you have asthma?
IF YES, YOU MUST HAVE YOUR INHALER WITH YOU DURING TREATMENT
19. Do you have any previous experience with Kambo medicine? If yes, when was the last treatment? How many burn points?
20. How did you hear about SPIRIT 11OUSE?
Additional Comments or anything else you would like us to know?
I hereby certify that I have accuratley and truthfully completed the above Confidential Client Form.
First and Last Name*
Today's Date*

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*I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance
Kambo Contraindications

Kambô is very safe but should always be taken with a properly trained practitioner administering and supervising the treatments at all times. Certain health conditions prevent some people from taking Kambô just like some situations require special precautions. Please read carefully the following lists, it is very important that you disclose your whole health history with your practitioner. If something is not clear or you don’t understand, please ask..

Contraindications

The following may not safely take Kambô:

People with serious heart problems
People who have had a stroke
People on medication for low blood pressure (this is extremely rare)
People who’ve had a brain hemorrhage
People who have aneurysms or blood clots
People who lack the mental capacity to make the decision to take Kambo
People with serious mental health problems excluding depression and anxiety
People undergoing chemotherapy or radiotherapy for 4 – 6 weeks afterward
People who take immune-suppressants for an organ transplant
Women who are pregnant or may be so
Women who are breast-feeding a child under 6 months old
People with Addison’s disease
People with Ehlers Danlos Syndrome
People with current and severe Epilepsy
Are recovering from a major surgical procedure
Under 18
Animals

Caution is also required in the following cases:

People taking immune-suppressants for auto immune disorders.
Active drug or alcohol addiction.
Long term or water fasting for 7 days before or after Kambo other than the required fasting.
Colonics, Enemas, liver flushes or any water based detox should be avoided within 3 days either side of taking Kambo.
If someone has taken Bufo 5-MeO-DMT there is a 6-8 week waiting period before Kambo.

Oesophagus/Esophagus Rupture
Because Kambo can cause violent vomiting we need to have some caution around certain conditions that could weaken the Oesophagus/Esophagus. These do not necessarily preclude you from experiencing Kambo but it is advisable to make sure to let your Practitioner know if you have been affected with any of the following:

Boerhaave’s Syndrome (spontaneous rupture of the oesophagus)
Severe injury, or trauma to the Oesophagus/Esophagus from endoscopy, or injury to the neck.
Tumours, or Ulcers in the throat
Those who have or have had bulimia
Gastro-intestinal Reflux
Chronic inflammatory response syndrome due to mold exposure
Untreated eosinophilic esophagitis
Oesophagus/Esophagus Varices
Portal Hypertension
Should be Empty:

IF YES, YOU MUST HAVE YOUR INHALER WITH YOU DURING TREATMENT

*I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance