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Plant Medicine Survey Form for Ceremony
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.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
WhatsApp or Phone Number to follow up for a short call. Please indicate which.
*
Your answer
Dates that work for you? Select all that apply.
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October 21st/22nd
October 28/29th
Do you have experience with plant medicine or psychodelics?
Yes
No
If yes to the previous, what plants or substances?
Your answer
What prescription medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What over the counter medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What herbs and supplements are you taking? (list all here as well as amount and how often you take them)
*
Your answer
Do you have a history of schizophrenia or bi-polar condition, siezures?
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Yes
No
Other:
Do you have a heart condition (problems or surgeries)?
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Yes
No
Other:
If yes to prior question provide details.
Your answer
Are you a Costa Rica resident (live in costa rica 10 out of 12 months a year), citizen, or visitor
Resident
Citizen
Visitor
Other:
Clear selection
Are you pregnant?
*
Yes
No
Do you have any food restrictions?
Your answer
Do you have any food allergies?
Yes
No
Clear selection
If yes to above, please list.
Your answer
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