Initial Assessment and Health Overview
To ensure that you have the best possible experience during your session, we would like to have some more information about your medical history, medication and any supplements. The information you provide will help us determine the appropriate dosage of the medicine and assess whether it is safe for you to undergo a journey. It is crucial that you provide this information honestly and in its entirety. Failing to do so can significantly impact your journey, overall well-being and even your life. Please inform us if you have ever experienced or are currently dealing with a physical or mental health condition, regardless of whether or not you are taking medication for it. In most cases, it is usually safe for you to continue your normal medication, but it's important to discuss this with us beforehand. By providing us with accurate and complete information, you allow us to ensure your safety and maximize the benefits of your experience.
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Contact in case of emergency?
How did you hear about us?
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Session Information
Which session do you want to attend?
Let us know if there is a specific event you would like to attend.
What is you dream outcome?
Please state which teachers you are hoping to work with:
Kambo
Grandfather
Grandmother
Sacred Teachers
Kambo
Kambo is a powerful medicine works deeply and needs to be respected so that we can tailor your experience to meet your needs. Rest assured that all information you provide is confidential, and any behaviours or recreational drug use will not be judged but rather taken into consideration during the treatment. We need a comprehensive overview of your health and well-being before proceeding. Please note that Kambo is entirely safe when administered by a properly trained practitioner. We are fully Certified Advanced Kambo Practitioners under the IAKP (International Association of Kambo Practitioners). You can find more information about this organization at www.IAKP.org. If you are menstruating at the time of treatment, please be aware that Kambo may potentially increase the flow for 24-36 hours due to its powerful vasodilators. If you have asthma, it is essential to have your inhaler with you during the session. If you have diabetes, it's important to discuss your treatment in advance. If you have been engaged in long-term water fasting, especially leading up to the treatment, it is crucial that you inform us.
Sacred Teachers
There is a psychedelic compound in mushrooms that affects serotonin receptors in the brain, leading to positive changes in perception, thoughts, and mood. There is a lot of research being carried out now that suggests that taking mushrooms can have positive effects on wellbeing. Some of the potential positive effects include: • Reduced symptoms of depression and anxiety. • Increased psychological well-being • Enhanced emotional openness and empathy • Alleviation of existential distress • Positive behaviour change
Grandmother
Grandmother sessions are intended to be a personal growth experience and should not be considered a substitute for psychotherapy but a complementary therapeutic device. Working with grandmother can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with Cardiovascular problems, serious hypertension, psychiatric conditions, recent fractures or surgery, acute infectious diseases, epilepsy or active spiritual emergencies. There is no empirical research data on the safety of grandmother in pregnant women. If you have any doubt as to whether you should participate in the session, it is essential that you consult your doctor or therapist, as well as the organisers of the session. Please answer all questions as fully and honestly as possible. Withholding the truth from this application form could risk your safety and of others in the session.
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Physical Health
Please complete this health form as thoroughly as possible:
Considering your age, how would you describe your overall health?
Excellent
Good
Fair
Poor
What is your current body weight?
Do you currently have any medical conditions?
Yes
No
If so, are you currently in the care of a health care professional?
Yes
No
Do you have a history or present condition of high or low blood pressure?
Yes
No
Describe any surgeries, major accidents, and hospitalizations:
Please check for present or past conditions if not sure leave blank:
Heart attack
Heart Disease
Stroke
High blood pressure
Low blood pressure
Brain Haemorrhage
Aneurysms or blood clots
Addison’s disease
Ehlers Danlos Syndrome
Anaemia
Anxiety Disorder
Asthma
Auto-Immune Disease
Bipolar Disorder
Cancer
Depression
Developmental Delays
Diabetes
Eating Disorders
Liver Disease
Psychosis
Schizophrenia
Epilepsy
Thyroid Disease
Serious mental health problems (excluding depression and anxiety)
Have you had Chemotherapy or radiotherapy in the last 6 weeks?
Are you taking Immune suppressants for an organ transplant?
Are currently expecting a baby or may potentially be pregnant
Date of last menstrual period:
Please circle check for present or past conditions if not sure leave blank:
Are you breast-feeding a child under 6 months old?
Do you have a history of endometriosis?
Are you recovering from a major surgical procedure?
Are you Under 18?
Have you had any form of surgery in the last 8 weeks?
Are you taking immune-suppressants for auto immune disorders?
Active alcohol or substance addiction?
Long term or water fasting for 7 days before or after Kambo other than the required fasting?
Colonics, Enemas, liver flushes or any water based detox in the last 3 days prior to Kambo?
Taken Bufo 5-MeO-DMT within the last 6-8 weeks?
Kambo Specifically : Conditions of the Oesophagus
Because Kambo can cause violent vomiting we need to have some caution around certain conditions that could weaken the Oesophagus/Esophagus. These do not necessarily preclude you from experiencing Kambo but it is advisable to make sure to let know if you have been affected with any of the following:
Conditions of the Oesophagus
Boerhaave’s Syndrome (spontaneous rupture of the oesophagus)
Severe injury, or trauma to the Oesophagus/Esophagus from endoscopy, or injury to the neck.
Tumours, or Ulcers in the throat
Those who have or have had bulimia
Gastro-intestinal Reflux
Chronic inflammatory response syndrome due to mold exposure
Untreated eosinophilic esophagitis
Oesophagus/Esophagus Varices
Portal Hypertension
Please describe any conditions you checked. Please indicate whether they are past or present.
Do you currently have any health challenges?
Have you had any health challenges in the past?
Do you use any recreational drugs?
Have you used any entheogens, psychedelics or other substances the in last 3 months?
Supplements
List all vitamins, minerals, herbs, homeopathics, and other health aids. (It is essential that you list ALL supplements) Supplement & Dosage. For What? For How Long?
What allergic reactions have you had? Check all that apply:
Antibiotics
Alcohol
Aspirin
Scents
Citrus
Dairy
Dust
Fumes
Molds
Grass
Penicillin
Pets
Pollen
Trees
Smoke
Weeds
Wheat
Codeine or morphine
Other
Please provide any other information you think might be relevant:
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