Psilocybin Health Questionnaire

Psilocybin Health Questionnaire for The Leela School of Awakening

I accept that all the data provided on this Health Questionnaire may be stored, processed, and analyzed by The Leela School, for the purpose of eligibility to partake in psilocybin. The Leela School strongly suggests you consult with your health care provider prior to applying for treatment using psilocybin. All information collected is stored in a HIPAA compliant manner and will not be shared with anyone other than Physician Reviewer (Bonny Koeber MD). If our reviewer has questions they may contact by you by phone or email.
1. What is your full name*
2. Phone Number*
Please enter a valid phone number.
3. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. What is your email address*
example@example.com
5. What is the date of your birth*

MonthDayYear
Date
6. What is your gender:
7. What is your profession or what do you primarily do?
8. Do you have a history of, or have you ever been diagnosed with any of the following psychiatric conditions? Please check answers:*

A Psychotic Disorder such as schizophrenia, schizoaffective disorder, depression with psychotic featuresA psychotic episodeDrug induced psychosisA personality disorder such as borderline personality disorderAny dissociative disorderBipolar disorder Type 1 (with mania)Bipolar disorder Type 2 (without mania / only depression)Bipolar disorder Type unknownManic episodeObsessive Compulsive DisorderMajor Depressive DisorderNoneOther
9. Have you recently (within the last month) taken lithium?*
10. Have you ever been diagnosed with a neurological disorder (Brain tumor, epilepsy, dementia, ALS, Parkinson's disease or multiple sclerosis?*
11. If you answered yes to question 10, would you mind explaining in the space below?
12. Have you ever, or do you currently, suffer from any of the medical problems listed below? Check any that apply:*

Heart rhythm disorderHeart failureAngina (chest pain) or heart ischemiaHeart AttackEnlarged heart or poorly functioning heartCongenital heart defect with symptomsBlood clotting disorderStrokeAsthmaHeart valve diseaseUncontrolled or poorly controlled hypertensionNoneOther
13. Have you ever been diagnosed with Insulin Dependent Diabetes?*
14. Do you have any problems with your liver?*
15. If you answered yes to the question above, please explain in the space below:
16. Do you have any problems with your kidneys?*
17. If you answered yes to the question above, please explain in the space below:
18. Have you ever used psychedelics?*
19. Which psychedelics have you used before? Check all that apply:

PsilocybinMDMAIbogaineAyahuascaMescaline (peyote, San Pedro)KetamineDMTSalva DivinorumLSDNoneOther
20. In what type of settings have you previously used psychedelics? Please check all that apply:

Ceremonial with clear intentionsRecreationalMicrodosingNoneOther
21. How many times have you used psychedelics (Excluding microdosing):

Once1-56-1011-2021-50More than 50Never
22. Have you ever had a challenging psychedelic experience that resulted in a difficult integration period and negatively impacted your life?*
23. If you answered Yes to the above question please explain:
24. Individuals with certain psychiatric conditions may be at increased risk of adverse psychological reactions when consuming psilocybin. These risks have not been extensively studied or quantified. Studies generally have excluded individuals at high risk for adverse events and negative outcomes such as in a patient with psychosis, bipolar disorder, or a family history of these conditions. Your psychological health is a crucial factor for the safe consumption of psilocybin. The use of psilocybin is weakly associated with triggering psychotic like symptoms. Dissociations to a large extent is explained by the presence of other psychiatric disorders and/or the use of other psychoactive substances.*

I agree that I do not have, to the best of my knowledge, any underlying psychological disorder listed under Question 8 above.I do not want to disclose any psychological disorders I may have.Other (Please explain in the box below):
25. Consuming psilocybin could possibly present additional risks for individuals experiencing thoughts related to self-harm or suicide. Have you ever been diagnosed with, or have you ever suspected you might suffer from depression?*
26. If you answered yes to the question above, please explain:
27. Have you ever been diagnosed with any form of PTSD or ever suspected that you suffer from trauma?*
28. If you answered yes to the question above, please explain:
29. Have you been diagnosed, or have you suspected you suffer from addiction or substance abuse disorder?*
30. If you answered yes to the question above, please explain:
31. Do you have or have you suffered from chronic pain?*
32. If you answered yes to the question above, can you please give us more information?
33. Would you be able to lie down for several hours during a psilocybin journey?*
34. If you answered no, would you please elaborate?
35. Have you ever attempted to take your own life?*
36. If you answered yes, would you please elaborate?
37. Have you ever been hospitalized for psychiatric reasons?*
38. If you answered yes, would you please elaborate?
39. Are you currently receiving mental health care services from a provider (psychiatrist, psychologist, therapist, counselor, or non-traditional healer?)*
40. If you answered yes, please provide their contact information below:
41. Are they aware of your desire to use psilocybin?
42. If you answered no, would you agree to inform them of your desire to take psilocybin?
43. Do you give us permission to contact them about your mental health?
44. If you were struggling physically, mentally, or emotionally after the use of psilocybin, would you feel comfortable seeking help and support from a mental health provider?*
45. Do any of your relatives suffer from a mental disorder?*
46. If you answered yes, which relatives have a diagnosis of a mental disorder?

ParentSiblingChildGrandparentUncle(s)Aunt(s)NoneOther
47. Have you ever experienced any type of sexual abuse or other types of traumas?*
48. If you answered yes, would you mind telling me more?
49. How would you respond to the following statement: "I feel I have emotionally processed any traumatic experiences in my life, and they no longer impact my day-to-day life in a negative way."*

I strongly disagreeI somewhat disagreeI agreeI somewhat agreeI strongly agree
The use of psilocybin can lead to transient adverse physical effects. The higher the dose, the more common and intense the effect. Additionally, the effects can vary depending on a person's genetic background, the use of certain medications, and the presence of certain physical conditions.
Cardiovascular: Psilocybin can cause transient increases in your heart rate and blood pressure. Psilocybin can cause adverse changes in your heart rhythm. Using psilocybin can be dangerous to people with cardiovascular conditions.
Gastrointestinal: Psilocybin can cause transient nausea, vomiting, diarrhea and other GI upset.
Hepatic: Psilocybin is broken down to its active ingredient in the liver. Taking psilocybin in the presence of liver impairment can be dangerous and influence the duration and intensity of the effects.
Renal: Psilocybin is eliminated from the body by your kidneys. The ingestions of psilocybin in the presence of kidney diesease can be dangerous and result in injury.
50. I have read the above information and*

I understand the above statements and realize I am responsible for the risks incurred.I do not understand and do not accept the risks inherent in taking psilocybin
51. What is your current height in inches or cm?
52. What is your current weight in pounds or kg?
53. Are you independent with your daily living activities?*
54. If you answered no, please elaborate. What do you need assistance with to accomplish your daily living activities?
55. Are you pregnant or planning to become pregnant?*
56. Are you breast feeding currently?*
57. Are there any health concerns you have that have not been covered in this questionnaire?*
58. If you answered yes to the above question, please elaborate:
59. Can you walk up a flight of stairs without stopping or becoming short of breath?*
60. If you answered no to the above question, please elaborate:
61. There has been much research on certain medications and psilocybin being taken at the same time. Many medications can be dangerous when combined with psilocybin. This is particularly true of medications used to treat depression, anxiety, mania, seizures, psychosis, bi polar disorder, schizophrenia, schizoaffective disorder, and hypertension. Please list ALL current prescribed medications and all over the counter medications that you take with the dosage and how often they are taken. (If you take none, please write NONE.)*
62. Please list any supplements or herbal medicines such as Ashwaganda, 5-HTP or St. John's Wort that you currently take (If you take none, please write NONE.):*
63. Would you experience unpleasant behavioral or emotional reactions if you were to stop taking alcohol or benzodiazepines (Valium, Ativan, Xanax) for several days?*

YesNoUncertainI do not take any of these medications or drink alcohol
64. Do you feel you are ready to meet physically, emotionally and mentally, any challenges that may surface during a psychedelic experience?*
65. If you answered no to the above question, would you please elaborate?
66. If you were uncomfortable or struggling during a psychedelic experience, would you be able to ask for assistance?*
67. Is your support circle (family, friends, etc) aware of your intention to participate in a psychedelic journey?
68. Will your family or support circle be supportive of your psychedelic journey?
69. What is the name and contact number of a person you would like us to contact in the case of an emergency?
Name*
How are they related to you*
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email address:*
Phone Number*
70. What is your intention for participating in a psilocybin journey? What challenges do you hope to overcome?
71. Is there anything else pertaining to your physical, emotional, or mental health that you want to share with me?
72. Do you have any food or drug allergies?*
73. Do you have any dietary restrictions or requirements?*
By signing this agreement , you are signing a waiver of release of liability, and agree that The Leela School's staff are acting only as facilitators and not a licensed medical professionals.
Signature

Clear
Date of signing

MonthDayYear
Date
Thank you for your time and honesty in filling out this lengthy questionnaire. It is designed specifically for your safety and physical/emotional well-being.
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Psilocybin Health Questionnaire for The Leela School of Awakening