Date*

Name*

Age*

Date of Birth*

Sex*

Address*

Phone Number*

E-mail Address*

Weight*

Height*

What is your purpose for seeking Ancestral Medicine?

Which medicine(s) are you interested in working with? Kambo, Bufo or Ayahuasca?

Do you have any doubts about moving forward with a medicine journey? What is your biggest fear relating to Sacred Plant & Animal Medicine?

Have you read the information provided by the practitioner, pertaining to your medicine of choice?

Are you mentally prepared to handle any effects resulting from your work with this medicine?

Are you physically in a position to work with this medicine (as outlined in the info/contraindications provided)?

Have you worked with Ancestral Medicine or psychedelics, in the past? If so, please provide a brief description of your experience(s), including dosage and how your life was impacted.

Do you consider yourself mentally healthy?

Do you have any current medical conditions?

Do you take any medications? Please list each pharmaceutical and what it is for.

Do you suffer from high or low blood pressure? Do you take medication for this condition?

Do you have any heart problems?

Do you ever experience difficulty breathing?

Do you currently or have you ever suffered from seizures?

Do you experience any pain or discomfort in your body? Is it chronic? Where in your body? Please rate the level of pain from 1-10.

Do you have any allergies or aversions?

How many hours of sleep do you get in a night?

Do you wake up feeling refreshed?

What are your go-tos for meals in a day?

How is your digestion? How many poops per day? Please describe any concerns.

Do you have any spiritual or contemplative practices to help you navigate through the emotional, mental and physical shifts that will likely occur during this process? Please describe.

Do you have any experience with fasting?

Have you ever been addicted to any substance? Are you currently addicted? Please explain usage.

Do you have any current or past psychological or psychiatric conditions or diagnoses? If so, please describe.

Do you suspect that you have an undiagnosed mental health issue?

Have you ever been hospitalized for a psychotic episode?

Have you ever taken medication to regulate your mood? Please explain.

Have you ever tried to commit suicide or had suicidal thoughts? Please explain.

Have you ever engaged in self-harm or destructive behaviour to yourself or another?

Do you currently see a psychiatrist, psychologist or counsellor? How often?

Would you seek out therapy if your life became unmanageable?

Have you experienced any trauma that you are aware of? Please explain.

Have you ever been abused physically, mentally, emotionally or sexually? Please explain.

Have you ever experienced spiritual abuse (with a religion or cult)? Please explain.

Do you believe in a Higher Power? (God, Universe, etc.)

Do you have trust issues? Please explain.

Do you ever experience anxiety, fear or paranoia? Please explain.

Plant and Animal Medicine can shake things up in a person’s life. Are you in a place where you can handle some instability for a period of time?

Do you have any spiritual or contemplative practice to help you navigate through the emotional, mental and physical shifts that will likely occur after a treatment? Please describe.

What are the coping mechanisms and self-care practices you use to deal with stress and challenges in life?

Can you ask for help, if you need it?

Do you have a support system to rely on when life becomes difficult? Please list names and phone numbers.

Do you have a person or network of people to assist you integrate this type of work?

What groups or communities are you a part of?

Is there anything else you want to share about yourself?

What languages do you speak fluently?