Kambo experience health questionnaire

1

Name* This field is required.

First Name

Last Name

2

Date of birth* This field is required.

Date

3

Email* This field is required.

example@example.com

4

Emergency contact (name, e-mail or phone number)* This field is required.

5

Have you done kambo before?* This field is required.

Never

1 - 4 occasions

5+ times

6

How many vaccines you received against COVID-19?* This field is required.

1 vaccine

2 vaccines

3 vaccines

4 or more vaccines

None

7

Are you pregnant or planning pregnancy?* This field is required.

Yes

No

Not applicable

8

Are you taking medication? Include Vitamins & Supplements. Please list all medication/s. If not taking any say "None".* This field is required.

9

List any medical and psychological conditions you have been diagnosed with? If you have no health conditions, please say "None".* This field is required.

10

Have you got any phobias? If yes, what kind?* This field is required.

11

Do you suffer from GERT? (Gastroesophageal reflux disease)* This field is required.

Yes

No

12

Do you suffer from any conditions that effect your digestive tract? (Stomach ulcers, Any previous Oesophagus/Esophagus bleeding or rupturę)* This field is required.

Yes

No

13

Have you experienced a serious psychological episode (e.g. nervous breakdown, psychosis) in the last 12 months?* This field is required.

Yes

No

14

Have you had a stroke?* This field is required.

Yes

No

15

Are you taking medication for low blood pressure?* This field is required.

Yes

No

16

Do you have any addictions? (Please include excessive drinking)* This field is required.

17

Do or have you ever suffered from any heart conditions? (Please include any investigations)* This field is required.

Yes

No

18

Have you had any surgery? If yes please provide dates for each.This might not affect your eligibility to have Kambo but is useful information to determine how Kambo will be applied to you.* This field is required.

19

What are you hoping to get out of your Kambo treatment/s?

20

Any other information you want to share?

21

Signature

Powered by Jotform SignClear