Medical Questionnaire

Medical Questionnaire

If you have any questions, please call us at +51 929 522 040 or email info@naturaliaretreat.com
Name

First NameLast Name
Gender
E-mail
Mobile number
Date of birth

DayMonthYear
Emergency Contact

RelationNamePhone NumberEmail
Have you had any injuries or accidents?
If yes, please specify:
Have you already participated to an Ayahuasca ceremony in the past?
Do you follow a specific diet?
Other diet or diet specification:

Do you have any of the following:

If you answered yes to any on the above, please specify the causes (for allergies, asthma, depression), and if you are taking/ took any prescription due any condition
Beside of the above, do you take any medication or tablets?
If yes, please mention the type and the consumption frequency:
Did/do you consume any type of drug?
If yes, please mention the type and the consumption frequency:
Do you drink alcohol?
If yes, please mention an average quantity and frequency:
Do you have any comments or special requests?
Terms and Conditions
Should be Empty: