Spirit Medicine - Ayahuasca Journeys


-Online Medical Questionnaire

Please answer the following questionnaire.

Also please let us know if you have any other health related problem not mentioned here.

First & Last Name:  
E-mail:  
Country:  
Occupation:  
Date of birth:   (dd-mm-yy)
Sex:   Male.  Female.
Marital status:  
Passport number:  
Contact in case of accident:  
Phone number:  

Answer the following questions only if affirmative.
Blank answers meanning NO.

Do you have any diseases? If yes, please, explain.

Do you have a psychological condition? If yes, please, explain.

Do you have any dietatary problems? If yes, please, explain.

Psychoactive substances use

Substance
Frequency
Last consumption
Cocaine
Crack
Opium, Morphine, Heroine
Marihuana / Hashish
Alcohol
Pharmicuticals
LSD
MDMA (Extacy)
Others

Are you currently taking any medication? If yes, please, explain.

Do you have any experience with modified states of consciousness?
If yes, please, explain.

Do you have any experience with ritual context use of psychotropic plants like San Pedro, Peyote, Ayahuasca, Hongos, Wilca, etc? If yes, please, explain.

Do you practice meditation, yoga, reiki, bioenergy or another self-exploration technique? If yes, please, explain.

How did you find us?

Do you have any problem not indicated in this questionnaire?
If yes, please, explain.

 



~ Heal your Body ~ Open your Heart ~ Awaken your Mind ~