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 medications used, prescription amount, and time of use for any of the checked above boxes.

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 or have had cancer? Please list any medications and for how long? If not write N/A

Do you have high or low blood pressure? Any medications

Any brain or spinal injuries? How long ago?

Briefly explain how it affects you?

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

How many Standard drinks do you consume on average?

What type of drugs and how much do you consume on average?

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?

Please list any other ailments that have not been mentioned. Please list the length of time medications have been used for any ailments.

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

IBOGAwaken

Full Intake Application

IBOGAwaken Full Intake Application

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