Kambo Cleanse Questionnaire Thank you for your interest in Joining us in Ontario! Please answer all questions.Be specific/Full Disclosure Required! Contact Information Name * First Name Last Name Birthdate * MM DD YYYY Email * Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contacts Please provide the name and phone number of 2 trusted emergency contacts. #1 Emergency Contact (Name & Phone Number): * #2 Emergency Contact (Name & Phone Number): * Medical and Health History I have read the list of Kambo Contraindications and I qualify for Kambo. Click HERE to see the list again Yes No List any medications you are currently taking or have taken in the past year. List supplements currently taking or have taken in the last year. Current medical conditions (pre/post surgery, disease, chronic issues, physical, mental and/or emotional) Do you have any fears or phobias? If yes please specify. Currently or in the past suffered from addiction, emotional, mental and/or psychological disorders (Assaults, Depression, Drug Addiction, Trauma)? If yes, please specify: What sort of assistance and/or work have supported you to manage your conditions? Are you currently taking medication for any diagnosed/medical psychiatric disorder(s) (examples: Depression, Bi-Polar, PTSD, OCD, ADHD)? Yes No If yes, please explain current condition, duration, medication using, and dosage: Have you experienced seizures, taking anti-seizure medication and/or been diagnosed with epilepsy? Yes No If yes, please explain your medication, dosage and duration of medication: Do you use stimulants, recreational drugs or plant medicines, etc? (Type, Dosage and/or Frequency) *In working with Kambo, it's important to have full disclosure of substance use This information is privileged and confidential Do you drink alcohol? Yes No Are you dealing with substance addiction/dependency? If yes, specify history and provide and current conditions: Have you been through rehabilitation whether a formal center or a specific program or even on your own for substance abuse? If yes, please specify history and current conditions: List any surgeries or operations and their year Examples include any time you've been under anesthesia, wisdom teeth removed, c-section, plastic surgery, cancer related, Transplant*, heart* etc: *Heart surgery and organ transplant are contradictions Do you have a diagnosed and/or known cardiovascular condition? If yes, please specify: Is there anything about your physical or mental state I need to be aware of? If yes, please specify: What do you hope to achieve by working with Kambo? * Tell me about your nutrition habits: A nutritional guru. Eats 100% clean whole foods Healthy habits. The 80/20 rule lifestyle 50/50 Is sugar healthy? Diet coke is life Other What is your occupation? Thank you!
