Plant Medicine Ceremony Medical Form

1

Full Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Email Address* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Do you have any known allergies? If yes, please list them.* This field is required.

6

Are you currently taking any medications? If yes, please list them.* This field is required.

7

Please indicate if you have ever been diagnosed with any of the following conditions (check all that apply):* This field is required.

Heart disease

Epilepsy or seizures

Diabetes

High blood pressure

Psychiatric conditions (e.g., depression, anxiety, bipolar disorder, schizophrenia)

None of the above

Other

8

Please describe any surgeries or hospitalizations you have had.

9

Do you have any current or chronic health issues not listed above? Please describe.

10

Emergency Contact Name* This field is required.

11

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

12

Have you participated in plant medicine before?

Yes

No

13

Which medicines have you worked with, and when?

14

Have you ever had a challenging experience with plant medicine?

Yes

No

15

Please describe the experience.

16

Do you have any diagnosed medical conditions?

Yes

No

17

Please list all conditions.

18

Do you have any allergies?

Yes

No

19

Please list your allergies.

20

Have you ever been diagnosed with a mental health condition?

Yes

No

21

Please list diagnoses.

22

Are you currently working with a therapist or psychiatrist?

Yes

No

23

Are they aware you are seeking this experience?

Yes

No

24

Are you currently taking any prescription medications?

Yes

No

25

List all medications and dosages.

26

Have you recently stopped taking any medications?

Yes

No

27

When and why did you stop?

28

Do you consume alcohol?

Yes

No

29

How often?

30

Do you use cannabis?

Yes

No

31

How often?

32

Do you have any mobility limitations?

Yes

No

33

Please describe.

34

Do you have any dietary restrictions?

Yes

No

35

Please list.

36

Are you taking any of the following? SSRIs, SNRIs, MAOIs, Benzodiazepines, Antipsychotics

SSRIs

SNRIs

MAOIs

Benzodiazepines

Antipsychotics

37

Have you ever experienced hallucinations, delusions, or psychotic episodes?

Yes

No

38

Do you have a history of suicidal thoughts or attempts?

Yes

No

39

Are you pregnant, breastfeeding, or trying to conceive?

Yes

No

40

Thank you for your honesty. Based on your responses, we will reach out to you privately to discuss safety and alignment before confirming your participation.