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
Your answer
City
Your answer
Country
Your answer
Birthdate
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DD
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YYYY
Profession
Your answer
Gender
E-mail
Your answer
Emergency Contact
Your answer
Phone Number of Contact
Your answer
Ceremony Date
MM
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DD
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YYYY
*******Medical Questions**********
Your answer
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:
Your answer
Please list any hospitalizations in the last 10 years?
Your answer
Do you suffer or have suffered from any of the following?
Required
Please enter in more detail here:
Your answer
*******Vida Personal Cuestionario*************
Your answer
What is your martial status?
Required
How is your relationship with your partner or how did your last serious relationship end?
Your answer
Are you dating at the moment?
Do you have children?
Required
How is your relationship with your children?
Your answer
How is your relationship with your family in general?
This can include both nuclear and extended.
Your answer
Have you had traumatic experiences in your life?
Such as assaults, accidents, wars, losing loved ones...
Your answer
Do you have any addictions?
Required
Please describe:
Your answer
Do you see a professional psychological medicine for any reason?
Required
Please describe:
Your answer
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?
Your answer
Why are you interested in taking ayahuasca?
Your answer
How did you find ShamanicVida?
Your answer
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