JACCRI Psilocybin Retreat Intake Form
Dear Participant,
 
Thanks for your interest in JACCRI Retreats. We ask that you fill out this intake form to help us be sure that the mushroom experience will be safe for you.  Be assured that all information you share with us will be held confidentially.  If there are any questions you don't feel comfortable responding to in writing, LEAVE BLANK, and we will talk about it over a telephone or video call.

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Do you have any current health concerns or issues?
Please list all the prescription and over the counter medications that you are currently using regularly.
Please list all prescription and over the counter medications that you use on occasion.
Please list all supplements (vitamins, minerals or herbs) that you routinely use.
Have you had any adverse reactions/allergies to medications? If so, please describe.
Do you have any other allergies?
Please list any major surgeries, hospitalizations or significant illnesses in your past, including approximate date.
What is your sensitivity to medications (for example, ibuprofen)? Does a regular dose usually work for you, or do you generally need more or less than others?
Do you have a history or cardiovascular disease?
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Do you have a history of diabetes?
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Do you have a history of heart rate/rhythm irregularity?
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Do you have a history of high blood pressure?
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Do you have a history of seizure disorder?
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Do you have breathing disorders, such as asthma?
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Do you have any kidney disorders/irregularities urinating?
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Do you have any history of liver disease?
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Please list any family history of cardiovascular disease? If so, please provide a brief description to the best of your understanding.
Are you under the care of a physician? When was your last physical exam?
How would you describe your energy levels?
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