FULL INTAKE FORM | IBOGAwaken

Please quickly explain the above checked box in terms of length of time and how it impacts your life.

Please list any pharmaceutical medications you are currently using — including both prescribed and over-the-counter. Indicate the dosage (amount) and the condition or purpose for which each is taken.

Are you currently experiencing any respiratory issues such as; severe asthma, sleep apnea, chronic bronchitis, emphysema, cystic fibrosis or any other? Please list any ailments and the medication taken and for how long.

Are you currently experiencing any heart issues such as; myocarditis/pericarditis, arrhythmia, heart disease, congenital heart defects or any other? Please list any ailments and the medication taken and for how long?

Any impaired kidney function or organ issues? Please list any ailments and the medication taken and for how long.

Do you currently have, or have you previously had, a cancer diagnosis? If yes, please specify any treatments or medications and the duration of use.

Do you have high or low blood pressure? Any medications?

Have you had any brain, spinal, or head injuries (including concussions)? If yes, please specify the type of injury and when it occurred.

Briefly explain how it affects you?

Thyroid issues? Has it been removed or currently taking medication?

On average, how many drinks do you consume? When was the last time you had alcohol, and approximately how much did you consume?

Please list any recreational substances, and plant medicines you are currently using or have used recently. Include the type, amount, frequency of use, and the date of last use.

Any neurological impairment such as; dementia, Alzheimer's disease, Epilepsy, Migraines, Parkinson Disease, multiple sclerosis. Please list ailments. Any medications taken presently or in the past and for how long?

Any type of Psychosis, bipolar, Schizophrenia, Depression, multiple personality disorder or any other? Please list ailments. Any medications taken presently or in the past and for how long?

Have you or are you currently using Opioids - codeine, Hydrocodone (Vicodin, Hycodan) Morphine (MS Contin, Kadian) Oxycodone (oxycotin, Percoset) Hydromorphe (Dilaudid) Fentanyl (Duragesic) or any other? Please list any medications taken presently or in the past and for how long? When was the last dose taken?

Have you or are you currently using Antipsychotics - Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole, Paliperidone, Lurasidone or any other? Please list any medications taken presently or in the past and for how long? When was the last dose taken?

Additional Ailments List any health conditions or ailments not previously mentioned.

Medication & Supplement Use Indicate the duration of use for all current medications, hormone therapies, and vitamin or supplement protocols, including the condition each supports.

Please tell us how healing with an Iboga ceremony would impact your life.

IBOGAwaken

Full Intake Application

IBOGAwaken
Full Intake Application

Qualifying Health Assessment & Disclosure Statement

Join our mailing list