FEAT Step 4: Medical History

Write a Medical History starting from conception to your current age. Please be detailed and honest as certain pre-existing conditions can cause cardiac issues during ibogaine treatment if not known and monitored closely. People in substance-abuse often minimize or conceal health problems or drugs in their system. The more details we have the better we can prepare and guide you through the journey of addiction interruption with ibogaine.

Your Name* This field is required.

First Name

Last Name

Your Phone* This field is required.

Email* This field is required.

example@example.com

Gender* This field is required.

Check any history of heart, lung, liver problems, seizures, or serious brain injuries. * This field is required.If you checked any of these please say more about it when you describe your medical history.

Have you ever been diagnosed with a mental illness?* This field is required.

YESNO

If Yes please list all diagnoses and which year you received that diagnosis

Mental Health ExplanationPlease describe any Mental Health condition checked above.

Do you have an ongoing relationship with any of the following professionals (check all that apply)

Therapist

Coach

Psychiatrist

Nutritionist

Have you ever had a charge/criminal conviction brought against you?

Yes

Other

Exercise* This field is required.

Sedentary

Mild Exercise (Climb Stairs, Walk 3 Blocks, Golf)

Occasional Vigorous Exercise (Less than 4X/Week for 30 Mins)

Regular Vigorous Exercise (4X/Week for 30 Mins or More)

How many Meals do you Eat per Day?* This field is required.

5 or More

Other

What is Your Diet Like?* This field is required.

I don't cook very much

I mostly heat premade/packaged meals

Restaurants/fast food/take-out

Gluten free

Vegan

Vegitarian

I eat meat nearly every meal

Paleo

Other

Are you on a Specified Diet prescribed by a health care practitioner? Please describe. * This field is required.

Cardiovascular* This field is required.

High Blood Presure

Leg Swelling/Pain

Heart Arrhythmia

Syncope/Dizziness

Chest Pain/Angina

Anemia

Heart Murmur

Palpitations

History of Heart Attack

None

Other

Digestive System* This field is required.

Nausea/Vomiting

Heartburn

Constipation

Abdominal Pain

Diarrhea

Hernia

Ulcers

Irritable/Inflammatory Bowel

Celiac

Liver Disease

Other

Endocrine/Immune System* This field is required.

Cancer

HIV/AIDS

Candida Infection

Diabetes

Adrenal Fatigue

Viral Infections

Chronic Infection

Bacterial Infection

Hypothyroid

Hyperthyroid

Other

Skin* This field is required.

Rashes

Psoriasis

Itching

Eczema

Wounds/Abscess

Wounds that Won't Heal

none

Other

Please explain any Physical Health Condition checked above

Sexual Abuse* This field is required.Have You Ever been Sexually Assaulted or Abused?

Yes

Not Sure

Other

Sexual Abuse Explanation

Current Home Life * This field is required.What is your Current Home Life like? Who do you Live with? Are the People you Live with Clean, Sober and Supportive?

Coping Skills* This field is required.

Nervous System* This field is required.

Headaches

Migraines

Memory Loss

Brain Injury

Dizzyness

Fainting

Seizures

None

Other

Respiratory* This field is required.

Difficulty Breathing

COPD

Shortness of Breath

Asthma

Sleep Apnea

None

Other

Muscles, Bones and Joints* This field is required.

Back Pain

Stiffness

Joint Pain

Swelling

Arthritis

None

Other

Kidneys, Bladder and Reproduction* This field is required.

Pelvic Pain

Kidney Disease

Burning/Pain with Urination

Frequent/Urgent Urination

STD's

Reproductive Condition

None

Other

Are you on Birth Control* This field is required.

Yes

Other

List type of Birth Control

When was your last Menstrual Cycle (if Applicable)

Are you taking Hormone Replacement Therapy (HRT)

Yes

Other

Have you ever have you ever been to a wellness or plant medicine retreat?

Yes

Please Explain* This field is required.

Overall Physical Wellness* This field is required.

Wonderful

Good

Could be Better

Not Good

General Health* This field is required.

Fatigue

Weight Loss

Weight Gain

None

Other

Where did You Grow Up?

How Would You Best Describe Your Childhood?* This field is required.

Traumatic Childhood* This field is required.Would You say You had a Traumatic Childhood?

Yes

Not Sure

Other

Traumatic Childhood Explanation

Sexual Abuse

Yes

Not Sure

Other

What Does Your Typical Day Look Like?

Are you currently Suicidal?* This field is required.(If you are currently suicidal or feeling unsafe, please go to the nearest Hospital, Crisis Centre or contact your local Suicide Hotline Immediately.)

YESNO

Have you ever attempted Suicide/Self Harm?* This field is required.

YESNO

Suicide ExplanationPlease Explain

Mental Health Conditions* This field is required.

Anxiety

Panic Attacks

Depression

Addiction

Nervousness

Insomnia

Suicidal Ideation/Thoughts

Bipolar Disorder

Personality Disorder

Depersonalization

Other

How Would You Best Describe Your Sleep Patterns?

Do you have Difficulty getting to Sleep or Staying Asleep? Do you Feel Restless? How many Hours of Sleep do you get on Average per Night?

Beliefs and Practices* This field is required.

What are Your Personal Beliefs and Practices, if any?

Moral/Spiritual Upbringing* This field is required.

What were your and/or your family's spiritual beliefs and practices growing up, if any?

Life Perspectives* This field is required.

How do You View Yourself and Others?

Surgeries* This field is required.

Please list all surgeries you have had in the past along with dates.

Have you ever been in a treatment for drugs or alcohol?* This field is required.

YESNO

If Yes Please Explain* This field is required.

When, Where and for How Long

Have you ever been admitted into hospital or facility for mental health reasons?* This field is required.

YESNO

Please Explain* This field is required.

When, Where and for How Long

Have you ever have you ever been to a wellness or plant medicine retreat?* This field is required.

YESNO

Electronics* This field is required.Are you Willing to be Without Electronic Devices for periods of time throughout your retreat? Family Members may reach Soul Reflections Staff at any time throughout the retreat.

YESNO

Sleeplessness* This field is required.Are you Willing to Experience Periods of Sleeplessness during your ceremonies?

YESNO

Iboga Ceremonies* This field is required.Are You Willing to Experience Discomfort throughout your Journey with Iboga? Including Nausea, Restlessness and Emotional Discomfort

YESNO

Do you have any Diet Restrictions? If so, please list.* This field is required.

Do you have any Allergies?* This field is required.

What is Your Average Daily Salt Intake?* This field is required.

Low

Medium

High

Other

What is Your Daily Sugar Intake?* This field is required.

Low

Medium

High

Other

Do You Drink any of the Following Caffeinated Beverages?* This field is required.

Coffee

Cola

Tea

None

Other

Emergency Contact* This field is required.

Give name, contact info and relation to you

What brings you to the Medicine ?* This field is required.

Anything Else

Is there Any other Information We Should Know About You

Up Next: Step 5, Substances Record