Medical History Form

Your details are confidential Information. Plant & Animal ceremonies are intended to be a personal growth experience and should not be considered a substitute for psychotherapy, but rather a complementary therapeutic device. Working with Mushrooms, Ayahuasca or Bufo Alvarius 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 pregnant women. Please answer all questions as fully as possible. Your answers are intended to help facilitators and are strictly confidential.

If you have answered ‘yes’ to any of the questions above, it is important to give specific details by emailing [email protected] to set up a phone call with facilitators. We cannot confirm your place at the session until we have received this form. Please read and sign the following declaration.

Medical Name *

Medical Name

First

Last

Email *

Age *

Phone *

Do you currently suffer from or have a family history of any of these ailments? *

Cardiovascular disease, including heart attack

High blood pressure

Psychiatric condition

Recent surgery

Past or current physical injuries

Diabetes

Epilepsy

Osteoporosis

Asthma

Liver and/or kidney conditions

Are you Pregnant? *

Have you ever been hospitalized for a psychiatric illness? *

Is there anyone in your family with a history of psychiatric disorders? *

Are you taking any medication? *

Are you currently receiving therapy or attending a support group? *

If yes, please specify:

Do you have experience with Plant Medicine? *

If yes, how many times?

Do you have any experience with Sacred Medicine? *

If yes, how many times?

Have you experienced adverse or particularly difficult experiences with plant or animal medicine that you have found hard to integrate? *

Emergency Contact Details: Name, Phone Number *

Please read and check all the following declarations. *

I declare that I have read and understood the information in this medical form.

I further declare that I have answered all the above questions fully and honestly .

I declare I have not withheld any information that could be important

As far as I am aware, my general heath is good

Date signed *

If you are human, leave this field blank.

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