Pre Treatment Questionnaire

1

Full Name

First Name

Last Name

2

Your Email

example@example.com

3

Your Date of Birth

Date

4

Emergency contactPlease give us a name, e-mail or phone number

5

Have you ever done Kambo before* This field is required.

Never

1 to 4 times

More than 5 times

7

Are you pregnant or planning a pregnancy?

YESNO

8

Are you taking medication? Include Vitamins & Supplements. Please list all medication/s. If you are not taking any medications, please state 'None'.* This field is required.

9

Please list 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 any Phobias? If yes, what kind?

11

Do you suffer from GERT (Gastroesophageal reflux disease)

YESNO

12

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

YESNO

13

Type a questionHave you experienced a serious psychological episode (e.g. nervous breakdown, psychosis) in the last 12 months?

YESNO

14

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

YESNO

15

Are you taking medication for low blood pressure?

YESNO

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.

18

Do or have you ever suffered from any heart conditions? (Please include any investigations).

19

Have you had any surgery? If yes, please provide dates for each.

20

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

21

Any other information you want to share?

22

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