Health History Intake
Your honesty and integrity are imperative on this form as there could be contraindications with the medicines used in this process. All information is confidential and held with integrity, and is meant to help your facilitators plan for the highest quality care and support during your cleanse. No answer to any question will automatically exclude you from this process.
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Email *
Name
Mailing Address
Phone Number
Referred By
Date of Birth
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Age
Gender
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Height
Weight
Medical History - pre-existing physical and mental conditions, injuries, surgeries, dental work, diagnoses, and the year the event occurred
Do you smoke tobacco or marijuana? How much and how often?
Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, or any other supplements? What are they, how much do you take, and how often?
Pharmaceutical Drug History - please list all prescription or non-prescription medications, how long you have been on them, and the dosage (including SSRIs, Heart or Blood pressure medications (STATINS), NSAIDS, aspirin, ibuprofen, acetaminophen, etc.)
Did you receive any Covid-19 vaccine? Which brand: Pfiser, Moderna, J&J etc?
How many Covid-19 boosters did you receive?
Have you noticed any adverse effects from the vaccines?
Have you had Covid -19?
Have you noticed any adverse long term effects from Covid-19?
Please list all of your known allergies to medications, herbs or foods
Have you ever been diagnosed with Cardiovascular conditions? High Blood Pressure? etc…
Have you ever been diagnosed with Epilepsy or a neurological condition?
Have you ever been in an institution for mental or physical health?
Does your family (or you) have any history of psychosis or schizophrenia?
Health conditions of parents and grandparents: Heart Disease? Neurological? Diabetes? Cancer? Other?
Do you have prior experience with plant medicine or psychotropics? If so, please describe your past experiences and frequency of experiences.
Please disclose all recreational drugs (such as cocaine, MDMA, Ketamine, etc.) that you have or are currently using along with an indication of when you last used them.
What is your experience with cleansing the body?
Have you ever been convicted of a felony?
Do you have any warrants out for your arrest? If so, what state?
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