Name
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First Name
Last Name
Birthdate
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MM
DD
YYYY
Email
*
Phone
*
(###)
###
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How would you like to be contacted?
Emergency Contact #1
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First Name
Last Name
Phone
*
(###)
###
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Emergency Contact #2
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First Name
Last Name
Phone
*
(###)
###
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I have read the list of Kambo contraindications and I qualify for Kambo.
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List any medications you are currently taking or have taken in the past year.
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List supplements currently taking or have taken in the last year.
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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.
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Currently or in the past suffered from addiction, emotional, mental and/or psychological disorders (Assaults, Depression, Drug Addiction, Trauma)? If yes, please specify:
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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)?
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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?
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If yes, please explain your medication, dosage and duration of medication:
Do you use stimulants, recreational drugs or plant medicines, etc?
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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?
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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:
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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:
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Is there anything about your physical or mental state I need to be aware of? If yes, please specify:
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What do you hope to achieve by working with Kambo?
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How many sessions are you interested in?
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Tell me about your nutrition habits:
What is your occupation?
How did you hear about us?
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