Application for Treatment- Non Detox

Application for Ibogaine Therapy (Non-Detox)

Awakening in the Dream San Miguel/ Botánicos Desintoxicación y Tratamiente Natural S.C.
Prior to proceeding with your Ibogaine experience, it is important to fill out the following medical and mental health assessment. Please answer all questions as accurately as possible, paying special attention to medical history and substance use profiles. Incomplete or false information can lead to unintended consequences that may greatly affect your treatment and could even lead to serious harm, including death. Please understand that most, if not all,of the Ibogaine related complications or deaths have occurred because of the use of opiates or other drugs taken during or immediately following treatment. Pre-existing heart problems, inaccurate reporting of dosages, or not disclosing other medications being consumed including psychiatric medications, all create an elevated risk when combing with Ibogaine. We ask you to return the application form as soon as possible so that we have sufficient time to evaluate you for any potential risks or contraindications and prepare you for a safe and productive treatment experience. If you are taking antidepressants, anti-convulsives, or other psychiatric medications it will be important to taper off them in the weeks-days preceding your treatment. This is important because Ibogaine works in the same pathways as many mental health medications. A greater length of time off of these medications will result in an improved treatment outcome. You can review the process of getting off of these medications with your personal prescriber, or we can provide detailed instructions on how to do this including supplement routines that you can begin immediately to aid in preparations. Contraindications for Ibogaine treatment include advanced liver disease with enzymes four times above normal levels, heart disease, pneumonia, morbid obesity, untreated diabetes, uncontrolled hypertension, hyper-coagulable states (increased risk for blood clots) and current active infections. If you have a history of any heart, kidney or liver conditions, we will need to accurately assess your situation in order help to prepare you for a safe treatment. If you have any chronic intestinal or digestive issues, we can also help you prepare for any exacerbation of these issues during or following your experience. Prior to your experience, it is important that you receive a medical checkup, including a resting EKG and the following blood tests: Basic Metabolic Panel, liver function panel, CBC with differential[QS35, BHc in Mexico]. For those 60years of age and older, we require an additional stress test to make sure that your body will be able to handle the potential intensity of this treatment. These tests need to be completed with your personal physician prior to acceptance and scheduling of your treatment. Thank you for your interest and we look forward to talking with you further.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Height*
Patient Weight*
Patient Gender*
Patient E-Mail*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What country are you in?
Do you have a passport?

yesno
How did you hear about us?
Who do you live with?*
Marital Status*
Emergency Contact*

Name

Relationship to you

Phoneemail

Address/City & State/ Zip Code
Name of Medical Care Provider/Doctor (We do not plan to contact your health care providers without your consent)

First NameLast Name
CityState
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Email
example@example.com
Name of Psychiatric Care Provider/Therapist (We do not plan to contact your health care providers without your consent

First NameLast Name
CityState
Psychiatric Care Provider Phone Number
Please enter a valid phone number.
Psychiatrist Email
example@example.com
Do need a referral for an ibogaine-informed therapist?
Reason for seeking Ibogaine Treatment:*
Goals for Ibogaine Therapy*
Please describe any previous experience with psychedelics or entheogenics:*
Mental Health and Psychosocial History
Have you been diagnosed with any of the following:*

DepressionBipolar DisorderAnxietyObsessive Compulsive DisorderADD/ADHDPersonality DisordersSuicidal IdeationSuicide AttemptsEating DisorderSchizophreniaSubstance Use DisorderPTSDEpisodes of PsychosisOther Mental Health/Behavioral issuesNever been diagnosed
Briefly describe any of the above and treatment received:*
How would you characterize your current mental health? *
Briefly describe any rehab programs you have experienced:*
What has worked for you to remain in recovery?*
Do you have family members or housemates with addiction issues?*
Have you lost friends or family to addiction issues?*
Describe your use of substances in the last 30 days:*
Describe your history of drug and alcohol use, eating disorders, or other addictive behaviors starting with original onset to present:*
How long have you been free of chemical dependency in the past?*
Do you believe people can live a happy life free of substances?*
What do you like to do when you are not using substances?*
Are you willing and prepared to experience a period of sleeplessness, restlessness and possibly discomfort after ibogaine treatment?*
What are your concerns or fears about the ibogaine process?*
What are your current goals for recovery?*
Are you willing to give yourself a year to integrate your experience?*
What is your after treatment plan?*
Will you seek therapy before and after this treatment? Are you currently in therapy?*
What is your educational background?*
What is your occupation and where do you work?*
Where did you grow up and what was your family life like?*
How do you handle emotional experiences?*
How would you describe your spiritual health?*
Can you outline your spiritual beliefs and practices?*
What is the thing you have worked hardest for in life?*
What do you value most in life?*
What have been the four happiest moments in your life?*
What were the four saddest moments in your life?*
Patient Medical History
Please list any allergies:*
known drug allergies, medications, food, environmental
How would you describe your current physical condition?*
When was the last time you saw a doctor and for what reason?*
Please list any surgeries, major illnesses or hospitalizations and the year:*
Description and date of any serious injuries or accidents:*
Please list any other health conditions or diagnoses you have or have had:*
Please describe any family history of serious illness or chronic illness:*
Siblings, Parents, Grandparents
Symptom Review

Do you have or have you ever had (Please check all that apply)
HEENT*

Dental Pain or infectionsGlaucomaSinus InfectionsNasal BlockageNone
RESPIRATORY*

AsthmaChronic CoughRecurrent BronchitisEmphysemaShortness of BreathSleep ApneaTuberculosisNone
CARDIAC/CIRCULATORY*

Angina/Chest PainHeart DiseaseArrhythmiaBradycardiaStroke/TIAVaricose VeinsEdema or swellingFaintingHigh blood pressureLow blood pressurePalpitationsNone
ABDOMINAL/DIGESTIVE*

Difficulty SwallowingAbdominal pain/bloatingDistress from fatty foods (nausea, dizziness, headaches, etc)Food AllergiesHypoglycemiaNauseaStomach ProblemsHeartburn/RefluxUlcersGallstonesHepatitis/Liver DiseaseH. PyloriJaundiceColitisConstipationDiarrheaChange in bowel habitsNone
GENITOURINARY*

Bladder infectionsFrequent UrinationKidney Disease/StonesSexually Transmitted DiseaseErectile DysfunctionProstate IssuesNone
GYNECOLOGIC*

Painful MenstruationExcessive MenstruationLoss of MenstruationBreast PainInfertilityUterine/Vaginal InfectionsNot Applicable or None
ENDOCRINE*

Diabetes Type 1Diabetes Type 2Thyroid IssuesReduced LibidoNone
NEUROLOGICAL*

TremorDizziness/VertigoEpilepsy/SeizuresWeaknessNumbnessMemory LossMigraines/HeadachesVision changesNerve damage/NeuropathyConcussionsNone
MUSCULOSKELETAL*

Arthritis/Joint PainSciatica/Low Back PainMuscle Pain/SpasmTendonitis/BursitisFracturesNone
INFECTIOUS*

CandidaChicken Pox/ShinglesHerpes I/IIHIVMeningitisMononucleosisNone
OTHER*

Alcohol or Substance abuseAnemiaBruising/Bleeding TendencyCancer/LeukemiaWeight problems/ChangesFatigueChemical sensitivitiesKnown toxic exposuresNone
Do you rely on any adaptive equipment or medical devices? Please describe.
ex.; CPAP, Oxygen, Walker, Cane, etc
Current Prescription Medications
Current Supplements
Health Habits
Exercise*

Never1-2 days/week3-4 days/week5+ days/week
What type of exercise/s do you do?
Alcohol Consumption*

I don't drinkDailyWeeklyMonthlyOther
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke or use nicotine?*

No0-1 pack/day1-2 packs/day2+ packs/dayNicotine other than cigarettes
Please describe your average daily diet:*
Any dietary restrictions or requirements?*
Include other comments regarding your Medical History
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