Kambo Pre-Screening Form
Please complete this short form before booking your 15-minute discovery call. Kambo is a powerful and potentially intense experience. For your safety, some conditions mean we cannot proceed with treatment. Please answer honestly and thoroughly. Your answers are confidential.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
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Why are you interested in sitting with Kambo?
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Have you sat with Kambo before?
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Yes
No
Are you currently experiencing, or have you ever been diagnosed with, any of the following? If you tick any of the below, unfortunately we cannot proceed with treatment. Please tick all that apply:
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Alcohol dependency
Addison’s Disease
Ehlers-Danlos Syndrome
Currently taking antiepileptic medication
Any brain conditions
Blood clots
Participated in Bufo or any other entheogenic treatments in the last 8 weeks
Currently undergoing or within 10 weeks of chemotherapy
Currently undergoing or within 10 weeks of radiotherapy
COVID-19 vaccination within the last 12 weeks
Currently taking diuretics or antidiuretics
Drug dependency (opioids, opiates, benzodiazepines — unless stopped 2–4 weeks ago)
Gastric sleeve or gastric band surgery
Any heart or cardiovascular conditions
Organ transplant or taking immune suppressants
Diagnosed with severe PTSD
Diagnosed bipolar disorder, schizophrenia, psychosis, or personality disorder
Hospitalised for a psychiatric condition or emotional crisis in the last 5 years
Medicated low blood pressure
Recent major surgery (within the last 12 weeks)
History of stroke, brain haemorrhage, or aneurysm
Currently pregnant or within 8 weeks postpartum
Currently breastfeeding (under 6 months)
Pancreatic issues
Stomach ulcers
Severe asthma
Under 18 years of age
Recent or ongoing water fast
Please tick here if none of the above apply.
Do you have any other diagnosed health conditions not listed above? If yes, please describe. If no, write NA.
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Are you currently taking any medications or supplements? If yes, list them here. If no, write NA.
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Is there anything else you'd like me to know before our call?
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