Name
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First Name
Last Name
Email
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Date of Birth
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MM
DD
YYYY
Have you received Kambo before? If so, how was your experience?
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Share a bit about yourself, how are you feeling generally right now? Any struggles? What do you do with your time?
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Are you currently taking any medication or supplements? Please share all that you take, dosage and what for.
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What is your diet like? do you avoid any foods? Any digestive issues?
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Any current or past health issues?
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How are your stress levels?
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Do any of the following apply to you?
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Are you on any contraception, past pregnancies or terminations? How is your monthly cycle?
Why do you wish to receive Kambo? Do you understand the process of the ceremony?
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Please add any other information or questions you may have
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I declare that all the information I provided in this questionaire regarding my past and current medical conditions and use of medication is true and correct. I understand that withholding information, particularly a contraindicated condition or medication, may pose a serious safety risk.
I understand the possible treatment symptoms include: nausea, vomiting, facial swelling, excessive sweating and headaches, dizziness and very rarely fainting.
Kambo is a traditional indigenous medicine and none of this information should be considered a promise of benefits, a claim of cures, a legal warranty or a guarantee of results. You should consult with a healthcare professional before altering or discontinuing any current medications, treatment or care, starting any diet, exercise or supplementation program, of if you suspect you might have a health condition.
