Kambo.Berlin Medical History Questionaire

Kambo treatments are safe when performed by an experienced practitioner. However, there are situations in which you may be temporarily or permanently contraindicated for Kambo.

Please fill out this questionnaire to the best of your knowledge. Your answers will ensure your own safety and help me identify any risks and tailor the treatment to your needs.

Name

First NameLast Name

Age

Adress

Street

Additions

Town

Postal Code

E-Mail

example@example.com

Phone

Country CodeArea CodePhone Number

Name of emergency contact

Phone of emergency contact

Country CodeArea CodePhone Number

1. Do you have Kambo experience?

NoYes

How was your process?

2. Have you had any encounter with Bufo or Iboga in recent weeks?

NoYes

If yes: how long ago?

3. Are you currently on medication or do you take supplements?

NoYes

If so, which ones? Since when, how often and in what dosage?

4. Do you use drugs or drink alcohol?

NoYes

If so, please tell me more about it. What do you take? How often? In what dosage? How would you describe your drinking habits?

5. Have you ever had to fight an addiction? Please note: addictions are not limited to drugs and alcohol.

YesNo

If so, please tell me more about it.

6. Do you have or did you have

Fears or phobiasSeizures or epileptic fitsBulimia or other eating disordersInjuries in the area of the oesophagus and stomach

Which of these apply to you, and how do they affect you? Leave empty if none.

7. Do you suffer from acute or chronic diseases?

NoYes

If so, on which one(s) and for how long? How does this disease manifest itself? How do you feel at the moment? What has the treatment been like so far?

8. How is your cardiovascular system? Have you ever had:

Serious heart problems, heart attacks, heart defects, etc.Stroke or cerebral haemorrhageAneurysms or blood clotsRecently undergone surgeryHigh or low blood pressure that requires treatmentOther impairments of the cardiovascular system

If so, please tell me more about it.

9. Do you suffer from mental health problems or has this been an issue in the past?

NoYes

If so, under which? Has a medical diagnosis been made?

10. Have you undergone chemotherapy or radiotherapy in the last six weeks?

NoYes

11. Have you had an organ transplant or need to suppress your immune response for any other reason?

NoYes

12. Women only: Are you pregnant, about to have your next period, or are you nursing a child less than 6 months old?

I`m pregnantI'm on the verge of menstruation or already have itI`m breastfeedingNon of the above

13. Did you get vaccinated against COVID-19? If so, were there any side effects? Or have you had difficulty getting fully recovered after infection, with or without vaccination?

14. Would you like to tell me anything else about your state of health that was not covered by the questions?

The data obtained in the questionnaire will be recorded in accordance with statutory data protection regulations and treated as strictly confidential.

By submitting the questionnaire, you confirm that the information you have provided is accurate. You acknowledge that Kambo is an intense experience and that adverse reactions can never be completely ruled out.

Favorite Day of Treatment

Medical history questionnaire prior to Kambo treatment