Plant Medicine Survey Form for Ceremony

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Medical Screen. Must be completed prior to entering into a ceremony.
ALL RESPONSES ARE CONFIDENTIAL AND PRIVATE. ALL INFORMATION WILL NOT BE SHARED WITH A THIRD PARTY.

Email *

First Name *

WhatsApp or Phone Number to follow up for a short call. Please indicate which. *

Do you have experience with plant medicine or psychedelics? *

Yes

Required

If yes to the previous, what plants or substances have you used socially or in ceremony? List all substances (Example : alcohol, cannabis, cocaine, mushrooms, MDMA, ayahuasca, kanna, etc...)

What prescription medications are you taking? (list all here as well as amount and how often you take them) *

What over the counter medications are you taking? (list all here as well as amount and how often you take them) *

What herbs and supplements are you taking? (list all here as well as amount and how often you take them) *

Do you have a history of schizophrenia or bi-polar condition, siezures? *

Yes

Other:

Do you have a heart condition or a history of heart problems (choose all below)? *

Yes

Angina

Heart Attack

Heart Failure

Arrhythmia

High Blood Pressure

Congenital heart conditionn

Other:

If yes to prior question provide details.

Are you a Costa Rica resident (live in costa rica 10 out of 12 months a year), citizen, or visitor *

Resident

Citizen (Born in Costa Rica)

Visitor

Other:

Are you pregnant? *

Yes

Do you have any food restrictions?

Do you have any food allergies? *

Yes

If yes to above, please list.

How many days will you be staying in Costa Rica after the ceremony?
*

1 day

2 days

3 days

5 days

1 week

2 weeks

Other:

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