Medical Questionnaire

Email^*

First name^*

Surname^*

Phone number^*

Address

Address Line 1 ^*

City ^*

Country ^*

Zip ^*

Birth date^*

Gender^*

Do yo speak English?^*

Yes
No

Ceremony information

Ceremony date

Order number

Questionnaire

Do you have a physical or mental condition at the moment?^*

Yes
No

Have you, or members in your family, ever suffered from: psychosis / bipolar disorder / borderline / schizofrenia / mania / delusions / severe anxiety / severe depression / suicidal thoughts? If so, which one, when and under which circumstances?^*

Are you under treatment of a physician or therapist, and if so, for which reason?^*

Are you taking medication - or alternative medication (including painkillers and nose-spray)? If so, which one?^*

Do you regularly drink alcohol or use drugs? If so, which one, how many and how often?^*

AYAHUASCA AND SAN PEDRO ARE NOT COMPATIBLE WITH THE CONSUMPTION OF ALCOHOL OR DRUGS, NOR WITH SOME ILLNESSES OR MEDICATIONS. BECAUSE THE SAFETY AND WELL-BEING OF ALL OUR GUESTS IS OUR HIGHEST PRIORITY, WE MAY ASK YOU TO STOP USING ALCOHOL, DRUGS AND/OR MEDICATIONS. THEREFORE, IT IS IMPORTANT TO HAVE YOUR PERMISSION FOR THE FOLLOWING:^*

I certify that I am willing not to use alcohol, drugs or medications for at least three days prior to attending the Ayahuasca or San Pedro ceremony/retreat (up to 8 weeks in some cases), and that I am willing to obtain permission from my physician to participate in the session when required of me by OMMIJ

Do you suffer (or have you suffered) from high blood pressure or heart disease (in the past)?^*

Yes
No

Are there any more details of a physical or emotional condition that could be important for us to know?^*

Do you already have experience taking Ayahuasca, San Pedro or any other entheogenic plant medicine?^*

Yes
No

Can you tell us a little about your motivation for participating in our ceremony or retreat (optional)

Medical questionnaire^*

I hereby certify that I have completed this Medical Questionnaire completely and truthfully. I certify that all information is correct and accept full legal & personal liability for participating in this ceremony/retreat, releasing OMMIJ from all legal liability

General conditions^*

I agree to the Terms and Conditions

Terms and conditions

Medical and Safety Guidelines^*

I hereby certify that I have read and agree to OMMIJ's "Medical and Safety Guidelines for Taking Ayahuasca and San Pedro (Huachuma)."

Medical and Safety Guidelines

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