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Plant Medicine Survey Form for Ceremony
Medical Screen. Must be completed prior to entering into a ceremony.
ALL RESPONSES ARE CONFIDENTIAL AND PRIVATE. ALL INFORMATION WILL NOT BE SHARED WITH A THIRD PARTY.
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Email
*
Your email
First Name
*
Your answer
WhatsApp or Phone Number to follow up for a short call. Please indicate which.
*
Your answer
Do you have experience with plant medicine or psychedelics?
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Yes
No
Required
If yes to the previous, what plants or substances have you used socially or in ceremony? List all substances (Example : alcohol, cannabis, cocaine, mushrooms, MDMA, ayahuasca, kanna, etc...)
Your answer
What prescription medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What over the counter medications are you taking? (list all here as well as amount and how often you take them)
*
Your answer
What herbs and supplements are you taking? (list all here as well as amount and how often you take them)
*
Your answer
Do you have a history of schizophrenia or bi-polar condition, siezures?
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Yes
No
Other:
Do you have a heart condition or a history of heart problems (choose all below)?
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Yes
No
Angina
Heart Attack
Heart Failure
Arrhythmia
High Blood Pressure
Congenital heart conditionn
Other:
If yes to prior question provide details.
Your answer
Are you a Costa Rica resident (live in costa rica 10 out of 12 months a year), citizen, or visitor
*
Resident
Citizen
Visitor
Other:
Are you pregnant?
*
Yes
No
Do you have any food restrictions?
Your answer
Do you have any food allergies?
*
Yes
No
If yes to above, please list.
Your answer
How many days will you be staying in Costa Rica after the ceremony?
*
1 day
2 days
3 days
5 days
1 week
2 weeks
Other:
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