Contact Information

Email

Emergency Contacts

Please provide the name and phone number of 2 trusted emergency contacts.

#1 Emergency Contact (Name & Phone Number):

#2 Emergency Contact (Name & Phone Number):

Medical and Health History

List any medications you are currently taking or have taken in the past year.

List supplements currently taking or have taken in the last year.

Current medical conditions (pre/post surgery, disease, chronic issues, physical, mental and/or emotional)

Do you have any fears or phobias? If yes please specify.

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?

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

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

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?

What is your occupation?

How did you hear about us?

Kambo Cleanse Questionnaire

Subscribe