Kambo Ceremony

Detox Treatment Information Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

Blood Type

Weight

Height

Profession

Emergency Contact Name + Number

1. Are you currently taking any medication?

Please indicate:

2. Are you currently taking any dietary supplements?

Please specify:

3. What is your day-to-day work like?

Please specify:

4. What is your everyday meal like?

Please specify:

5. Do you have a chronic illness?

Please specify: Please list the symptoms: Current treatment: Follow-up treatment:

6. Do you currently have any health problems?

Please specify: Please list the symptoms:

7. Have you had any accidents / traffic accidents?

If so, which ones and when?

8. Do you have any fears or phobias?

Please specify:

9. Do you suffer or have you suffered in the past with a mental disorder?

If so, which type?

10. Are you currently taking any medication for yes no a mental disorder?

Medicine and dose:

11. Have you been diagnosed with seizures and/or epilepsy?

If yes, do you take any medication?

12. Do you smoke?

If yes, how often?

13. Do you drink alcohol?

If so, how often and what kind?

14. Are you addicted to drugs or alcohol?

Please indicate:

15. Have you recently had an operation or operations?

If so, what kind and when?

16. Do you have a cardiovascular problem?

Please indicate:

17. Have you had an operation on your heart?

Please indicate:

18. Do you have children?

Please indicate:

19. Are you pregnant or breastfeeding?

Please indicate:

20. Do you have or what is your menstrual cycle?

Please indicate:

21. Is there something about your body or mental state, yes no that you think I should know?

Please specify:

22. Have you already had experience with this detox treatment?

If yes, when?

23. What is your reason/intention for this detox treatment?

Declaration of Consent

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

The above-named participant hereby declares and confirms having been fully and comprehensively informed about the treatment

The participant hereby confirms the following: - that no operations have taken place within the last 6 months before the treatment. - that no regular (daily) intake of medication has taken place, at least 4 weeks before the treatment - that no anti-depressants have been taken for at least 4 weeks prior to the treatment - that there is no heart rhythm disturbance - that there is no heart surgery - that no consumption of mind-aging substances has taken place within the last 4 weeks before the treatment - that you deem to be fit & healthy - if the intake of medication, mind-altering substances as well as health restrictions are not communicated, the participant bears full responsibility for the consequences or consequential damages. The participant hereby confirms that he/she has read and understood the above points and hereby confirms his/her agreement. The participant assumes complete responsibility for the retreat and hereby releases the management from any liability.