Kambo Cura Retreat - Questionnaire
22-29 March 2021 Gran Canaria
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Name *
Date of birth
MM
/
DD
/
YYYY
E-mail *
Phone number *
What is your motivation to join the retreat? *
Have you done Kambo before? *
Required
Dietary requirements *
Questionnaire *
Yes
No
Do you have serious heart problems or have you had heart surgery? This includes a Pacemaker but excludes Stents.
Have you had a stroke or a brain haemorrhage?
Do you have an aneurism or blood clot?
Are you recovering from a major surgical procedure with internal stitches?
Are on medication for low blood pressure?
Are undergoing chemotherapy, radiotherapy or have done so within the last 4 weeks
Do you have mental health problems?
Do you have a history of bipolar disorder, manic depression or schizophrenia?
Have you had an organ transplantation?
Do you have Addison’s Disease?
Do you have epilepsy?
Do you have EDS?
Could you be pregnant?
Are you breast-feeding a baby under 6 months old?
Have you worked with Bufo Alvarius in the last 2 months prior to Kambo?
Do you use weight loss products, serotonin and/or sleeping pills?
Do you use immune suppressors for autoimmune diseases?
Do you have an alcohol or drug addiction?
Have you worked with Iboga in the last 90 days?
Are you planning to fast 7 days before or after the Kambo?
Have you recently had an enema, colon flushing, liver flushing or a water-based detox?
Have you had bulimia or anorexia?
Do you have diabetes?
Do you have astma?
Do you have liver or kidney problems?
Do you regularly use anti diuretic medication or sports drinks?
Do you have an abnormal high or low blood pressure?
Do you have any other chronic or serious health problems?
Have you understood all the above questions?
If you have entered 'yes' above (with the exception of the last question), please explain. Or if you haven't, say 'not applicable': *
Is there another physical/psychological issue that has not been discussed? *
Required
Have or will you use medication, drugs or plant medicines in the months prior to the retreat? If yes, enter what for and when so we can check the required minimum abstinence period prior to Kambo. *
Cancellation policy *
Required
Disclaimer *
Required
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