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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?
Yes
No
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)?
*
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:
Clear selection
Are you pregnant?
*
Yes
No
Do you have any food restrictions?
Your answer
Do you have any food allergies?
Yes
No
Clear selection
If yes to above, please list.
Your answer
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