Kambo Questionaire English

Kambo treatments are a very safe affair when performed by an experienced practitioner. However, there are scenarios where Kambo is contraindicated.

Please complete this questionnaire to the best of your knowledge. The answers are for your own safety and help me to identify risks and tailor the treatment to your needs.

Name

First NameLast Name

Age

Adress

Street

Additions

TownCountry

Postal Code

E-Mail

example@example.com

Phone

Country CodeArea CodePhone Number

Emergency Contact

Country CodeArea CodePhone Number

1. Are you currently on medication?

YesNo

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

2. Do you suffer from chronic diseases?

YesNo

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?

3. Are you suffering from an acute illness?

YesNo

If so, which one and for how long? How do you feel? What has the treatment been like so far?

4. Do you suffer from fears or phobias?

YesNo

If so, under which? What effects do they have on you?

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

YesNo

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

6. Have you had seizures in the past or have you been diagnosed with epilepsy?

YesNo

If so, please tell me more about it.

7. Do you use stimulants and/or drugs?

YesNo

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

8. Do you drink alcohol?

YesNo

If so, please tell me more about it. How often do you drink alcohol? How do you rate your drinking habits?

9. Do you suffer from bulimia or is there another reason why your esophagus and stomach could be weakened?

YesNo

If so, please tell me more about it.

10. Have you ever had to fight an addiction? Important: Addictions are not limited to drugs and alcohol.

YesNo

If so, please tell me more about it.

11. Have you had any surgery or major surgery lately?

YesNo

If so, please tell me more about it.

12. Did you or did you have heart problems?

YesNo

If so, please tell me more about it.

13. Have you ever had a stroke or a cerebral hemorrhage?

YesNo

14. Have you ever had an aneurysm or a blood clot?

YesNo

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

YesNo

16. How would you describe your blood pressure?

normalrather highrather low

17. If you checked "rather low": Are you taking medication to increase or maintain your blood pressure?

YesNo

18. Have you undergone chemotherapy or radiotherapy in the last four weeks?

YesNo

19. 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

20. What supplements do you take?

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

22. 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?

The data collected in the questionnaire is collected in accordance with the statutory data protection regulations and treated with absolute confidentiality.

Hereby I declare the correctness of my data.

Medical History Questionnaire Kambo-Treatment