Shamanic Vida - ENG
To help save trees and Mother Earth, we use this electronic form. The following is a private questionnaire about your medical/ personal history we go over with the shamans. It is very important to fill out this form honesty it is a tool to help us learn more about you, what areas we need to focus on, how to help and work deeply with you. Asunki and blessings!
Last Name - First Name *
City *
Country *
Birthdate *
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Profession
Gender *
E-mail *
Emergency Contact *
Phone Number of Contact *
Ceremony Date *
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*******Medical Questions**********
Type of diet
Are you currenty taking any medicines? *
Other = If yes, please describe.
Required
Do you have any allergies? *
Other = If yes, please describe.
Required
Do you have any heart troubles? *
Others = If yes, please describe.
Required
Do you have any blood pressure conditions? *
Other = If yes, please describe.
Required
Have you had a concussion? *
Other = If yes, please describe with quantity.
Required
Do you suffer from asthma? *
Other = If yes, please describe with severity.
Required
Do you have any infectious or contagious diseases? *
Other = If yes, please describe.
Required
Do you have any psychological conditions? *
Other = If yes, please describe.
Required
Is there a history of psychiatric disorders in your family? *
Other = If yes, please describe.
Required
Do you suffer from epilepsy? *
Required
Are you pregnant or breastfeeding? *
Required
Please write any surgeries you have had in the last 5 years:
Please list any hospitalizations in the last 10 years?
Do you suffer or have suffered from any of the following? *
Required
Please enter in more detail here:
*******Vida Personal Cuestionario*************
What is your martial status? *
Required
How is your relationship with your partner or how did your last serious relationship end?
Are you dating at the moment?
Do you have children? *
Required
How is your relationship with your children?
How is your relationship with your family in general?
This can include both nuclear and extended.
Have you had traumatic experiences in your life? *
Such as assaults, accidents, wars, losing loved ones...
Do you have any addictions? *
Required
Please describe:
Do you see a professional psychological medicine for any reason? *
Required
Please describe:
Do you have experience with altered states of consciousness?
Do you practice any disciplines?
With what frequency do you drink alcohol? *
With what frequency do you use cannabis? *
With what frequency do you use cocaine? *
With what frequency do you use opiates? (pills, heroin, morphine) *
With what frequency do you use MDMA or ectasy? *
With what frequency have you used psychotropic plants ? *
Do you have any questions, doubts or concerns you would like to address?
Why are you interested in taking ayahuasca?
How did you find ShamanicVida?
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