The Medicine Angel

Instagram Youtube Whatsapp

The Medicine Angel

Instagram Youtube Whatsapp

Medical Screening Questionnaire

Medical Screening Questionnaire

Your wellbeing is very important to us and your health and safety during the retreat is our upmost priority.

You are almost done booking your spot...

Please complete the mandatory health questionnaire form below.

Is this the first time Ayahuasca plant medicine experience for you?
Are you currently taking any medications?
If so, please name them, the dosage, frequency and how long you have been on the medication(s).
Have you been taking any antidepressants within the last 40 days?
If so, please name them, the dosage, frequency and how long you have been on the medication(s).
Do you have any history of heart related concerns?
ie, hypertension (High Blood Pressure, Arrhythmia, Tachycardia, Heart attacks, Heart surgery, stents, shunts etc.
Have you ever experienced a seizure, stroke or been diagnosed as epileptic or diabetic?
If yes, please provide details
Do you or anyone in your immediate family (parents or siblings) have schizophrenia or Bipolar disorder?
If yes, please provide details