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Medical Questionnaire

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1 Please enter your personal details here

First Name *
Last Name *
Email *
Phone
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Country *
Birth Date *
Occupation
Emergency Contact Info *
How did you hear about Caya Shobo? *
Please share with us your reasons for visiting Caya Shobo *
Do you have any experience with regards to plant medicine, or shamanic rituals or ceremonies?
Are you currently in therapy or any type of support group?
Do you have a past history of, or currently suffer from any of the following?	Cardiovascular disease, heart attacks, strokes/infarctions High / low blood pressure A history of fainting Mental illness, psychosis, schizophrenia, suicide attempts, behavioural disorders Recent surgery Past or recent physical injuries (incl. fractures or dislocations) Recent or current infectious or communicable diseases Tumours/Cancer Epilepsy/Seizures Diabetes Asthma Glaucoma or retinal detachment Other health problems
Please provide details
Have you ever had any type of seizure?
Do you have any allergies?
Have you ever been hospitalized for medical reasons?
Have you been hospitalized for psychiatric reasons?
Are you currently pregnant or breastfeeding?	YES NO
Have you ever taken SSRI or SNRI medication for depression or anxiety? Please provide details
Are you currently taking any medications? Please list	Please note that it is imperative that you provide an accurate and detailed list of medications.
Please list any medications or vaccines you have taken over the past 12 months (prescribed or over the counter). Include dosage and frequency	Please note that it is imperative that you provide an accurate and detailed list of medications.
Please list supplements (herbs, vitamins, etc) you have taken regularly in the past 12 months.
Have you ever used any type of psychoactive substance?	Alcohol Marijuana/Hashish Cocaine Ecstasy Crack/Amphetamines Heroin/Morphine/Other Opiates LSD/DMT/Other Psychedelics Ketamine Other
Please indicate how many times you have used these substances, and when was the last time
Do you consider yourself addicted to one of these substances? Please elaborate
Have you had any incidents or accidents involving the use of these substances?
List any recreational substances that you have taken over the past 12 months (including alcohol and marijuana). Please include frequency of use	Please note that it is imperative that you provide an accurate and detailed list of recreational substances.
Anything else about your physical, emotional or mental status that you would like to share or that we should be aware of?
Terms and Conditions *	I accept the terms and conditions.Please read the terms and conditions