Nourished Soul Kambo Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date

Date

Birth Time

Hour Minutes

AM/PM Option

Birth Place

City, State, Country

Height

Weight

Emergency Contact Information

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please describe your top 3 areas of concern (Ex. Depression, anxiety, disease, cancer, weight gain, spiritual connection, anger, heartbreak etc) Where do you feel these concerns stem from?

How would you describe your current health?

Have you ever sat with Kambo? How many times, when was your last ceremony? Any concerns from previous ceremonies?

How did you hear about Nourished Soul? (Referral, website, social media, etc.)

Sleeping

What is the quality of your sleep?

Screen Time (phone/tablet/tv)

Exercising

Self Care (meditation, grounding, praying, painting, singing, etc)

Working

History with Eating Disorders

How would you describe your current diet?

Have you done any cleanses, fasting, parasite or colon cleanses in the past? Which ones and how recently/often?

What major surgeries or health issues have you had in the last 20 years?

Are you missing any organs? Which ones? Year of Removal?

Are you currently taking any pharmaceutical medications or supplements? Please list along with the dosage.

Have you taken any medicines, supplements or drugs in the last 7 days including hGH? Which Ones?

Have you taken any vaccines, flu shots, Covid etc in the last 2 years? (please list)

History of taking steroids, growth hormones, testosterone, estrogen?

History of Asthma

Do you have any blood issues such as blood clots, high blood pressure etc? Please explain.

History of Esophageal Disorders? Please Explain.

History of seizures or fainting?

Do you regularly have drinks with ice in them? How much?

Do you regularly drink alcohol? How many drinks per week? Please be honest (no judgement)

Have you recently (last 6 months) used psychoactive substances? Which ones and how often? Do you have a history of addiction? Please explain

Cerebral

Rows	Never	Rarely	Occasionally	Often	Almost Always
Chronic High Stress
Inability to handle stress
Decreased memory
Difficulty to focus
Increase in learning difficulty
Depression
Feeling hopeless, negative thoughts
Feeling overwhelmed / anxious for no reason
Anxiety
Sensitive to noise

Cellular Energy

Rows	Never	Rarely	Occasionally	Often	Almost Always
History of anemia
Low body temperature
Dry Skin
Weight gain
Constipation
Palpations of the heart
Difficulty falling asleep / staying asleep
Fatigue
Cravings for sugar and sweets
Tired all the time

Immunological

Rows	Never	Rarely	Occasionally	Often	Almost Always
Frequent diseases
Chronic symptoms sinusitis or infection
Chronic fatigue
History of the use of antibiotics
Chronic candida / yeast infections
Inflammation of the tonsils
Diarrhea
Infection / fungus on the toes
Always go to the hospital to receive antibiotics
Dark circles / black bags under the eyes

Digestion

Rows	Never	Rarely	Occasionally	Often	Almost Always
Excess belching after meals
Burning in the throat or burning of the stomach
Stretching / difficulty moving bowels
Diarrhea
Bad gas odor
Nausea
Hemorrhoids
Intestinal pain
Use of laxatives
Swelling of the stomach

Circulation

Rows	Never	Rarely	Occasionally	Often	Almost Always
Abnormal or irregular pulse
Injuries heal slowly
Cold hands or feet
Dizziness
Headache
Chest pain
Abnormal blood pressure
Varicose veins
High Blood pressure
Swollen ankles or hold water

Neuro Muscular

Rows	Never	Rarely	Occasionally	Often	Almost Always
Muscular weakness
Muscle spasms
Muscle pain
Pulsating pains in the extremities
Strange sensations in the skin
Weakness or loss of muscle control
Sciatica
Tremors
Uncontrolled spasms
Muscles always hurt

Hormonal

Rows	Never	Rarely	Occasionally	Oftern	Almost Always
Difficult getting out of bed / prefer to keep sleeping
Dizziness when getting up
Thirsty all the time
Ringing in the ears. High or low tones
Acne
Dizziness

Inflammation

Rows	Never	Rarely	Occasionally	Often	Almost Always
Chronic joint pain
Headaches
Chronic digestion or chronic constipation
Hypertension
Exzema or other skin problems
Frequent allergies
High cholesterol
Rashes on feet
History of gallstones or gallbladder problems
Bitter taste in the mouth in the morning

Women Only

Rows	Never	Rarely	Occasionally	Often	Almost Always
Irregular periods
Hot flashes
Adult acne
Hair loss or thinning

Are you pregnant/ Is there a possibility you could be?

Men Only

Rows	Never	Rarely	Occasionally	Often	Almost Always
Decreased libido
Lack of physical energy
Depression episodes
Difficulty urinating

If you have any other concerns regarding your health or well being, please share more here.

Welcome to Nourished Soul Kambo Services! Before we begin your healing journey, please review the following key points to ensure a clear understanding of our services:

Acknowledgment of Complementary Therapy: I understand that Kambo is a traditional healing ritual and a complementary therapy. It is not a substitute for medical treatment, diagnosis, or professional healthcare. I will continue to seek medical advice and treatment from my healthcare providers as needed.

Consent to Receive Kambo: I consent to receive Kambo, understanding that it is a non-invasive but intense therapy involving the application of frog secretion to the skin. I acknowledge that the process may involve physical and emotional cleansing, and my participation is voluntary. I am aware that I can withdraw consent at any time before or during the session.

Confidentiality Agreement: I understand that all information shared during Kambo sessions will be kept confidential. The practitioner will not disclose any personal details without my consent unless required by law.

Release of Liability: I release the practitioner from any liability or responsibility for any outcomes, results, or reactions experienced during or after the Kambo session. I acknowledge that I am participating voluntarily and am fully responsible for my own health and well-being.

By signing below, I confirm that I have read, understood, and agree to the above statements.

All of the facts in this form are true to the best of my knowledge and beliefs

Kambo Ceremony Intake Form

In a typical day, how many hours do you spend doing the following?

Choose the frequency of the symptoms for each

Kambo Service Acknowledgment and Consent Form