Temple of Rooted Radiance

Below you will find a series of questions regarding your previous medicine experience, your interest in connecting, as well as your physical and mental/emotional health.

It is important that you answer every question truthfully and thoroughly so that I can effectively assess the safety of hosting you for a journey.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

How did you hear about the Temple of Rooted Radiance?

What kind of experience are you interested in?

Personal ceremonyGroup ceremonyEntheogenic Sound HealingThree or six month immersion

What inspires you to contact the Temple today?

Please share briefly about your previous experience with medicine work (just taking a pulse about your familiarity with this question, not looking for a comprehensive history)

Cardiovascular issues/diseases

	yes	no
heart attack
angina
irregular heartbeat/arhythmia
deep vein thrombosis (DVT)
blood clots
significant high/low blood pressure

Blood Borne Pathogens

	yes	no
diabetes
hepatitis
hiv/aids

Respiratory Issues

	Yes	No
COPD
Chronic Bronchitis
Asthma
Emphysema
Phemonia

Neurological Health

	Yes	No
Stroke
Transient Ischemic Attack (TIA/mini-stroke)
Aneurism
Epilepsy
Seizures
Recent Head/Brain Injuries
Concussion or Bleeding Brain Lesion
Anything else affecting the brain, nerves, or spine?

Please describe the situation if you answered "yes" to anything above.

Mental Health (including you and/or family)

	yes	no
Schizophrenia
Psychosis
Manic-Depression
Bipolar Disorder
Borderline Personality Disorder
Dissociative Identity Disorder
History of Suicide
Obsessive Compulsive Disorder
PTSD or CPTSD
Anxiety
Depression

Psychiatric Medications

	Yes	No
SSRIs (selective serotonin re-uptake inhibitors)
MAOIs (mono-amine axidase inhibitors
NDRIs (norepinephrine dopamine re-uptake inhibitors)
Tricyclics

Please describe the situation if you answered "yes" to anything above .

Please list any supplements, herbal supplements, prescribed, over-the-counter medications, or other medications that you are taking here.

Intake & Health Screening