Medical History Form
Sol Sapo
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Check the conditions that apply to you:
Asthma
Bipolar
Cancer
Cardiac disease, including heart attacks
Depression or anxiety
Diabetes
Epilepsy
Hypertension
Psychiatric disorder
Low blood pressure
High blood pressure
Recent surgery
Past or recent physical injuries (fractures or dislocations
Diagnosed Mental illness
Diabetes
Infectious or communicable diseases
Other
Check the symptoms that you're currently experiencing:
Chest pain
Respiratory
Cardiac disease
Circulation
Bladder/kidneys
Back pain
Head/neck pain
Liver
Ability to sleep
Eyes/ears/nose
Intestines/bowel
Hematological
Lymphatic
Weight gain
Weight loss
Other
Are you pregnant or breastfeeding?
Yes
No
Are you currently taking any medication?
Yes
No
If yes, please list all medications including dosage and frequency taken. **Please note that it is imperative that you provide an accurate and detailed list of medications, as Kambo can dramatically increase the effects of certain medications to the point of becoming dangerous**
List any medications that you have taken in the past 12 months. (Prescribed or over the counter) Please include dosage and frequency taken.**Please note that it is imperative that you provide an accurate and detailed list of medications, as the plant medicine can dramatically increase the effects of certain medications to the point of becoming dangerous.**
List any supplements (herbs or vitamins) that you have taken regularly in the past 2 months.**Please note that it is imperative that you provide a complete list of any supplements taken regularly, as the plant
Have you ever been hospitalized for medical reasons?
Please Select
Yes
No
Please elaborate.
Have you ever been hospitalized for psychiatric reasons?
Please Select
Yes
No
Please elaborate.
Do you sit with any recreational substances and/or plant medicines?
Please Select
Yes
No
Please specify.
What kind of substances or plant medicines? How long have you used/been using them? How frequently?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Have you ever had any type of seizure?
Please Select
Yes
No
Continue
Continue
Are you currently taking any medication for any psychiatric disorder, SSRI medication for depression or other issue? Examples: Prozac, Seroxat, Zoloft, Effexor, Paxil, Welbutrin (bupropion), Zyban ,Pristiq, Cymbalta, Ixel, Effexor, Tramadol, Tramal, Ultram, Sibutramine, Meridia, Reductil, Axiomin, Etonin, Lubazodone, Serzone, Nefadar, Trazodone, Desyrel, Strattera, Edronax, Vivalan, Focalin, Ritalin, Concerta, Adderall, Dexedrine, Desoxyn, Vyvanse, Elavil, Endep, Evadene, Clomipramine, Anafranil, Desipramine (Norpramin, Pertofrane), Amoxapine (Asendin), Maprotiline (Ludiomil), Mianserin (Bolvidon, Norval, Tolvon), Mirtazapine (Remeron),Isocarboxazid (Marplan), Moclobemide, Aurorix, Manerix), Phenelzine (Nardil), Pirlindole (Pirazidol), Selegiline , Eldepryl, Zelapar, Emsam, Tranylcypromine (Parnate), Lithium, or other
If yes- What and when?
Reason for medication
For how long?
Are you taking any painkillers?
Please Select
Yes
No
Are you taking medication to quit smoking (Wellbutrin (bupropion), Zyban)?
Please Select
Yes
No
Is there anything else about your physical or mental health that we should be aware of?
What are your intentions for receiving sacred medicine? What are you hoping to gain or experience by working with these medicines?
Please be aware that the list of contraindicated substances includes, but is not limited to, SSRIs, Demerol, cold medication, decongestants, sinus medication, nasal sprays, hay fever medications, diet pills, amphetamines, MDMA or ecstasy, cocaine, ketamine, LSD, heroine, and crack. If you have been using any drugs, medical, over the counter, or street, please advise Ellee and/or the organizers of Sol Sapo prior to attending any Kambo Ceremony to discuss this matter further.
Please note that ceremonies should not be seen as, nor are they designed to be, a substitute for psychiatric or medical care.
I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information.
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