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Have you experienced adverse or particularly difficult experiences with ayahuasca that you have found hard to integrate?
Do you have a past history of, or currently suffer from any serious health conditions? Give details
Have you ever been hospitalized for medical reasons or had any surgeries? (If yes, please describe)
Do you have any heart or blood pressure issues? (If yes, please describe)
Do you suffer from any heart conditions? (If yes, please describe)
Do you suffer from any lung or repository problems? (If yes, please describe)
re you currently taking any type of medications? If yes, please list the medications dosage and frequency taken. (Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous.)
Do you suffer from epilepsy?
Do you suffer from diabetes?
Do you have any history of depression, anxiety, addictions or PTSD?
Do you have any history of psychosis, bipolar illness, personality disorder or schizophrenia?
Have you ever taken SSRI medication for depression? If so when? For how long?
Have you ever been hospitalized for psychiatric reasons? (If yes, please describe)
List any medications that you have taken in the past 12 months, prescribed or over the counter. (Please include dosage and frequency taken.)
Have you taken the covid-19 Vaccine. If So, how long ago:
List any recreational substances that you have taken over the past 12 months. (Including alcohol and marijuana)
What is your purpose for drinking Ayahuasca?
Have you suffered from any past emotional trauma that we should know about? Please give details.
Additional Information you would like the Shaman to know:
