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SACRED SOUL THERAPY HOUSE MEDICAL HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential.
Full disclosure of all information is important for safety purposes. Failure to disclose all information could result in disqualification from one of our programs.
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Name
Your answer
Email Address
Your answer
Phone Number
Your answer
DOB
MM
/
DD
/
YYYY
Sex
Male
Female
Marital Status
Single
Partnered
Maried
Seperated
Divorced
Widowed
Clear selection
Have you ever had an EKG?
If yes, when and for what reason.
Your answer
Have you ever had a Liver Panel Test?
If yes, when and for what reason.
Your answer
Date of last physical exam:
MM
/
DD
/
YYYY
PERSONAL HEALTH HISTORY
Check All Current Conditions:
Sleep Apnea
Asthma
Heart Condition
High Blood Pressure
Low blood pressure
Liver Condition
Kidney Condition
Blood Clots
List any medical problems that a doctor has diagnosed.
Your answer
Do you suffer from:
Check all that apply.
Anxiety
Addiction
Viral Infection
Depression
Candida Infection
Depersonalization
Surgeries
(Please list the years, reasons and hospitals)
Your answer
Other hospitalizations
(Including mental health hospitalizations and drug/alcohol treatment programs)
Your answer
List any prescribed and/or over-the-counter medications that you are currently taking (including vitamins, herbs, inhalers, etc.)
(Please list the names of drugs, strengths, frequency and length of time taken)
Your answer
Allergies or Sensitivities to medications or food
(Please list the names of food or drugs and the reactions you had)
Your answer
HEALTH HABITS AND OTHER
Exercise
Sedentary (No exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Clear selection
Do you consider yourself physically healthy?
Yes
No
Clear selection
Diet
Are you dieting?
Yes
No
Clear selection
If yes, are you on a physician prescribed medical diet?
Yes
No
Clear selection
# of meals you eat in an average day?
Your answer
Rank your salt intake
Low
Medium
High
Clear selection
Rank your sugar intake
Low
Medium
High
Clear selection
Rank your fat intake
Low
Medium
High
Clear selection
Caffeine
Type
None
Coffee
Tea
Cola
Clear selection
# of cups/cans per day?
Your answer
Alcohol
Do you drink alcohol?
Yes
No
Clear selection
If yes, what kind?
Your answer
How many drinks per week?
Your answer
Are physically addicted to alcohol?
Yes
No
Clear selection
Have you considered stopping?
Yes
No
Clear selection
Have you ever experienced blackouts?
Yes
No
Clear selection
Are you prone to “binge” drinking?
Yes
No
Clear selection
Do you suffer from DTs or shaking if you stop drinking?
Yes
No
Clear selection
Tobacco
Do you use tobacco?
Yes
No
Clear selection
Cigarettes -#/day
Your answer
Chew - #/day
Your answer
Pipe - #/day
Your answer
Cigars - #/day
Your answer
# of years
Your answer
Or year quit
Your answer
Sex
Do you suffer from any STDs?
Yes
No
Clear selection
If yes, please list condition(s):
Your answer
For women, are you currently on prescription birth control?
Yes
No
Clear selection
Have you ever been sexually assaulted or abused?
Yes
No
Clear selection
MENTAL HEALTH
PLEASE EXPLAIN ANY “YES” ANSWERS IN THE SPACE PROVIDED BELOW
Do you suffer from any phobias?
Yes
No
Clear selection
Do you suffer from OCD?
Yes
No
Clear selection
Do you feel depressed?
Yes
No
Clear selection
Do you suffer from panic attacks?
Yes
No
Clear selection
Do you suffer from PTSD?
Yes
No
Clear selection
Have you experienced a traumatic childhood?
Yes
No
Clear selection
Have you ever suffered a psychotic break?
Yes
No
Clear selection
Have you ever been suicidal?
Yes
No
Clear selection
Are you currently suicidal?
Yes
No
Clear selection
Have you ever been diagnosed with schizophrenia?
Yes
No
Clear selection
Have you ever been diagnosed with bi-polar disorder?
Yes
No
Clear selection
Do you have an eating disorder?
Yes
No
Clear selection
Are you currently under the care of a mental health professional?
Yes
No
Clear selection
Please explain any “yes” answers below.
Your answer
Other
Have you ever taken iboga or ibogaine in the past?
Yes
No
Clear selection
Have you experienced other plant/shamanic medicines in the past?
Yes
No
Clear selection
Do you consider yourself spiritually healthy?
Yes
No
Clear selection
Do you consider yourself mentally healthy?
Yes
No
Clear selection
Do you consider yourself “ready” for a change in your life?
Yes
No
Clear selection
DRUG HISTORY
Do you currently use recreational or street drugs?
Yes
No
Clear selection
Are you having problems getting off of a drug or medication?
Yes
No
Clear selection
Please list drug(s) that you are addicted to here and the daily dosage:
Your answer
Have you ever taken Suboxone or Methadone in the past?
Yes
No
Clear selection
Have you ever taken opiates (Heroin, Oxycodone, OxyContin, Vicodin, Percocet)?
Yes
No
Clear selection
Have you ever given yourself street drugs with a needle?
Yes
No
Clear selection
Are you currently taking any benzodiazepines (Ativan, Xanax, Valium, Klonopin)?
Yes
No
Clear selection
Are you currently taking a medication for sleep?
If yes, please list below
Yes
No
Clear selection
Your answer
Are you currently taking any ADD/ADHD medication (Adderall, Ritalin, Concerta)?
Yes
No
Clear selection
Are you currently taking any medications for depression and/or anxiety?
Yes
No
Clear selection
Do you currently smoke Marijuana on a regular basis?
Yes
No
Clear selection
Do you currently use cocaine, meth, crack or other major stimulant on a regular basis?
Yes
No
Clear selection
Please explain any yes answers here or any other information we should know:
Your answer
OTHER CONDITIONS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin Problems
Joint pain
Liver Problems
Kidney Problems
Chronic Infections
Respiratory Issues
Chest/Heart Conditions
Back Pain
Intestinal Problems
High Blood Pressure
Low Blood Pressure
Circulation Problems
Cognitive Problems
Weight loss/gain
Thyroid Conditions
Insomnia
Bowel Problems
Other:
Please explain any yes answers here.
Your answer
Is there any other information we should know about?
Your answer
Please explain your reason(s) for wanting Iboga treatment below.
Your answer
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