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IbogaQuest
Apply Form
DateTime
Name
*
Firts name
Last name
Age
*
Phone
*
E-mail
*
Country
*
State, Province or Region
*
City
*
Gender
*
Male
Female
Other
Please specify your gender
Residential Situation
*
Emergency Contact Name and Relationship
*
Emergency Contact Phone
*
Do you have a Passport?
*
No
Yes
What languages do you speak?
*
Do you have any current or pending legal issues?
*
No
Yes
Please specify current or pending legal issues
*
Employment Status
*
Employed
Self-employed
Unemployed
Are you responsible for children?
*
No
Yes
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Height
*
Weight
*
Do you have dietary restrictions or preferences?
*
No
Yes
Please specify your dietary restrictions or preferences
*
Do you have allergies?
*
No
Yes
Please specify your allergies
*
Are there any current physical conditions or needs IbogaQuest needs to be aware of?
*
No
Yes
Please specify the current physical condition that IbogaQuest needs to be aware of
*
Are there any medical conditions you hope ibogaine will help with?
*
No
Yes
Please specify the medical condition that you hope ibogaine will help you
*
Do you engage in regular physical activity?
*
No
Yes
Do you take prescription medications?
*
No
Yes
Please provide details about the prescription medications you are using, including the type, dosage amount, and the time you consumed it
*
Do you take over-the-counter medications?
*
No
Yes
Please provide details about the over-the-counter medications you are using, including the type, dosage amount, and the time you consumed it
*
Do you use illicit substances?
*
No
Yes
Please provide details about the ilicit substance you are using, including the type, dosage amount, and the time you consumed it
*
Do you drink alcohol?
*
No
Yes
What is your alcohol of choise? How often? How much?
*
What is the longest time you have been without a drink in the past year?
*
Ignore this question if you have never drank alcohol
Do you smoke?
*
No
Yes
How Often? How much?
Have you had a physical examination within the past 2 years?
*
No
Yes
If active HIV/AIDS or Hepatitis, what is the current viral load?
Do not fill out this field if you do not have any of these diseases
Have you ever been diagnosed with any of the following medical conditions?
*
Stomach problems
Respiratory problems
Urinary problems
Diabetes
Diarrhea
Constipation
History of ulcers
Thyroid problems
Liver problems
Renal disease
Jaundice
History of seizure
Headaches
Heart disease
Heart problems
Stroke
High blood pressure
Low blood pressure
Tuberculosis
Asthma
Back problems
Abdominal pain
Numbness
Joint pain
Nerve damage
Heartburn
Shaking
Nausea
Dizzy spells
Fainting
Slow heart rate
Shortness of breath
Muscle spasm
Swelling
Varicose veins
Bleeding
Menstruation problems
Cancer
None
Other
Have you had any surgeries?
*
No
Yes
Please specify your surgeries
Do you have a therapist?
*
No
Yes
Do you feel your therapist will support you through ibogaine therapy?
*
No
Yes
Do you have a history of detox/rehab?
*
No
Yes
Please explain in detail your detox/rehab hisotry
*
Do you have a history of self-injury?
*
No
Yes
Please explain your history of self-injury
*
Have you been diagnosed with any of the following psychological conditions?
*
Post Traumatic Stress Disorder- PTSD
Major Depressive Disorder
Depression
Attention-Deficit/Hyperactivity Disorder (ADHD)
Anxiety Disorder
Personality Disorders
Suicidal Attempts
Suicidal Thoughts
Internet Compulsion Disorder
Panic and Claustrophobia conditions
Eating Disorders
Sleep-Wake Disorders
Obsessive-Compulsive and Related Disorders -OCD
Schizophrenia
Somatic Symptom Disorder
None
Other
Have you ever been hospitalized for a mental condition?
*
No
Yes
Please specify the mental condition
*
Do you engage in regular meditation?
*
No
Yes
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What are your reasons for seeking ibogaine therapy?
*
Have you ever tried psychedelics?
*
No
Yes
List psychedelics experienced
*
Have you ever tried ibogaine/iboga?
*
No
Yes
Please provide details on when, where, and why you used ibogaine/iboga
Anything else to know
*
No
Yes
Please share any other important information or details that you think we might find helpful
How did you learn of Iboga Quest?
*
Internet Search
Referral (past attendee)
Referral (aftercare provider)
Spotify Podcast
Social Media
Other
When were you hoping to schedule your treatment?
*
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