HEALTH SCREENING FORM

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Please carefully go through this health screening form to make sure that having Sacred Medicine is safe for you. Once you submit the form I will review your application & respond shortly after. It's important to answer in detail and very honestly as there are risks for some people and this type of healing work isn't suitable for everyone.

Also please check your junk/spam folder for my response to your health screening form.

Thank you!

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What is your full name, gender and age?*

What is your email & phone number?*

Emergency contact: *

Who referred you?*

Do you have any experience with plant medicine? (If so please share which ones and how often you take them.)*

Do you take any recreational substances including drugs and/or alcohol? If so please share which ones and how often.*

Do you have a history of substance abuse? If so please explain.*

Are you taking any other drugs like caffeine, pain killers or allergy medications?*

Are you on any prescription medications? If so which ones and what dosage are you taking/ how often?*

Are you on medication for low blood pressure (High Blood Pressure is usually fine)*

Are you taking any of the following supplements: Kratom, mood stabilizing supplements, natural sleep aids, diet pills?*

Do you have any pre-exisitng medical conditions? If so please explain.*

Do you have a serious heart problem? Have you had heart surgery. Do you have a pacemaker? or a Stent?*

Have you had a stroke or a brain haemorrhage?*

Have you had an aneurism or blood clot?*

Do you have an active brain injury?*

Are you pregnant or breast-feeding a child under 6 months old?*

Have you been vacciniated with CV19 vaccine? If so, how many times and when?*

Do you have any of the following: cardiovascular issues, liver & kidney, head injuries, history of seizures, respritory issues or drug allergies?*

Do you have Addison's Disease?*

Do you have current and severe epilepsy? Are you taking medication for it?*

Are you recovering from a major surgical procedure with internal stitches?*

Are you undergoing chemotherapy, radiotherapy or have done so within the last 4 weeks?*

Are you taking immune-suppressants after an organ transplant?*

What is your weight in KG?*

Do you have any history with mental illness? If so pease describe.*

Do you have a history of PTSD or suffer from acute trauma? If so please explain.*

Do you have any of the following: schizophrenia, schizophrenic tendencies, borderline personaility disorder, seratonin syndrome, bipolar disorder or suicidal tendencies?*

Please share any major traumas that have happened in your life (including childhood traumas) and any therapies or treatments you have accessed.*

Do you have any types of Eating Disorders?*

Please share about what is calling you to ceremony at this time. *

What resources do you have in your life to support you? Example: Meditation practice, therapist, coach ect.*

Do you have any food sensitivities?*

Is there anything else that you wish to share? Do you have any further questions? *

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