Currently or in the past suffered from addiction, emotional, mental and/or psychological disorders (Assaults, Depression, Drug Addiction, Trauma)? If yes, please specify: *

What sort of assistance and/or work have supported you to manage your conditions?

Are you currently taking medication for any diagnosed/medical psychiatric disorder(s) (examples: Depression, Bi-Polar, PTSD, OCD, ADHD)? *

Yes

If yes, please explain current condition, duration, medication using, and dosage:

Have you experienced seizures, taking anti-seizure medication and/or been diagnosed with epilepsy? *

Yes

If yes, please explain your medication, dosage and duration of medication:

Do you use stimulants, recreational drugs or plant medicines, etc? *

Type, Dosage and/or Frequency - *In working with Kambo, it's important to have full disclosure of substance use.* This information is privileged and confidential

Do you drink alcohol? *

Yes

Are you dealing with substance addiction/dependency? *

If yes, specify history and provide and current conditions:

Have you been through rehabilitation whether a formal center or a specific program or even on your own for substance abuse? If yes, please specify history and current conditions: *

List any surgeries or operations and their year *

Examples include any time you've been under anesthesia, wisdom teeth removed, c-section, plastic surgery, cancer related, Transplant*, heart* etc: *Heart surgery and organ transplant are contraindications

Do you have a diagnosed and/or known cardiovascular condition? If yes, please specify: *

Is there anything about your physical or mental state I need to be aware of? If yes, please specify: *

What do you hope to achieve by working with Kambo? *

If you could change any aspect of your life in the next 90 days what would it be? How would this benefit your life?

Tell me about your nutrition habits: *

A nutritional guru. Eats 100% clean whole foods

Healthy habits. The 80/20 rule lifestyle

50/50

Is sugar healthy? Diet coke is life

Other

What is your occupation?

How did you hear about us? *

Thank you!

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DISCLAIMER: The use and application of our products and services is at the customer’s discretion, responsibility, and risk. All information provided is purely meant for historical, scientific and educational purposes and should never be interpreted as a recommendation for a specific use. Products are offered for their ethnographic and historical value only.

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Kambo Cleanse Questionnaire

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