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.

Name
Your answer
Email Address
Your answer
Phone Number
Your answer
DOB
MM
/
DD
/
YYYY
Sex
Marital Status
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:
List any medical problems that a doctor has diagnosed.
Your answer
Do you suffer from:
Check all that apply.
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
Do you consider yourself physically healthy?
Diet
Are you dieting?
If yes, are you on a physician prescribed medical diet?
# of meals you eat in an average day?
Your answer
Rank your salt intake
Rank your sugar intake
Rank your fat intake
Caffeine
Type
# of cups/cans per day?
Your answer
Alcohol
Do you drink alcohol?
If yes, what kind?
Your answer
How many drinks per week?
Your answer
Are physically addicted to alcohol?
Have you considered stopping?
Have you ever experienced blackouts?
Are you prone to “binge” drinking?
Do you suffer from DTs or shaking if you stop drinking?
Tobacco
Do you use tobacco?
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?
If yes, please list condition(s):
Your answer
For women, are you currently on prescription birth control?
Have you ever been sexually assaulted or abused?
MENTAL HEALTH
PLEASE EXPLAIN ANY “YES” ANSWERS IN THE SPACE PROVIDED BELOW
Do you suffer from any phobias?
Do you suffer from OCD?
Do you feel depressed?
Do you suffer from panic attacks?
Do you suffer from PTSD?
Have you experienced a traumatic childhood?
Have you ever suffered a psychotic break?
Have you ever been suicidal?
Are you currently suicidal?
Have you ever been diagnosed with schizophrenia?
Have you ever been diagnosed with bi-polar disorder?
Do you have an eating disorder?
Are you currently under the care of a mental health professional?
Please explain any “yes” answers below.
Your answer
Other
Have you ever taken iboga or ibogaine in the past?
Have you experienced other plant/shamanic medicines in the past?
Do you consider yourself spiritually healthy?
Do you consider yourself mentally healthy?
Do you consider yourself “ready” for a change in your life?
DRUG HISTORY
Do you currently use recreational or street drugs?
Are you having problems getting off of a drug or medication?
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?
Have you ever taken opiates (Heroin, Oxycodone, OxyContin, Vicodin, Percocet)?
Have you ever given yourself street drugs with a needle?
Are you currently taking any benzodiazepines (Ativan, Xanax, Valium, Klonopin)?
Are you currently taking a medication for sleep?
If yes, please list below
Your answer
Are you currently taking any ADD/ADHD medication (Adderall, Ritalin, Concerta)?
Are you currently taking any medications for depression and/or anxiety?
Do you currently smoke Marijuana on a regular basis?
Do you currently use cocaine, meth, crack or other major stimulant on a regular basis?
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.
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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.