Client Information Form - Exclusive Ibogaine Retreat

Patient Personal Details
Emergency Contact Information
Drug History
Medical History
Metabolism
Tell us more about yourself
Intentions

Patient First Name *

Personal Details

Patient Surname *

Personal Details

Address *

Personal Details

City *

Personal Details

Province or State *

Personal Details

Postal/Zip Code

Personal Details

Country *

Personal Details

Passport / ID Number *

Personal Details

Phone

Personel Details

Cell *

Personal Details

Email *

Personal Details

Skype

Personal Details

Weight *

Personal Details

Height *

Personal Details

Date of Birth *

Personal Details

Marital Status *

Personal Details

Dependants *

Personal Details

Primary Physician Name *

Personal Details

Physician Phone *

Personal Details

Health Insurance *

Personal Details

Health Insurance Information *

Personal Details

Note: International Clients are required to obtain a Travel Insurance or advise your current Medical Insurance Provider of your travel arrangements.

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Emergency Contact's Full Name *

Emergency Contact Information

Relationship *

Emergency Contact Information

Address *

Emergancy Contact Information

City *

Emergency Contact Information

Province or State *

Emergency Contact Information

Phone *

Emergency Contact Information

Cell *

Emergency Contact Information

Email *

Emergency Contact Information

What substance(s) are you seeking detoxification from? Please list amount or dosage, what form(s) you take it in and how often you use: *

Drug History

Are any of these substances prescribed to you by a doctor or therapist? If so please provide details: *

Drug History

Have you ever been abstinent from the substance/s you are seeking to detoxify from? If so, how long did this period of time last?

Drug History

If so, what did you find helpful in maintaining abstinence?

Drug History

Please describe your usual withdrawal symptoms (if any): *

Drug History

Do you drink alcohol? (If yes, please provide details below when asked about other substances that you use) *

Drug History

Do you smoke tobacco? *

Drug History

Do you use Cannabis? (Please provide details about your cannabis use below when asked about other substances. Please also provide details about what forms you use it in, such as whether you smoke it, eat it etc... Please be specific.) *

Drug History

Are you using any other substances? If so, please list amount or dosage, what form you take it in and how often (Please include all other substances including alcohol or any other legal or illegal substances): *

Drug History

Please provide a detailed chronological history of your substance use (Please list dates and details of your use. ie: 1990 - 1994 injected heroin twice a day and smoked crack 3 -5 times on weekends): *

Drug History

Please list other detox or treatment programs you have participated in, and tell us why they did or didn't work for you: *

Drug History

Have you had Oral or Implant Naltraxone in the last 60 Days *

Drug History

Have you participated in Narcotics Anonymous or Alcoholics Anonymous?

Drug History

Have you ever tried ibogaine therapy before? *

Drug History

If so, please provide an account of your ibogaine therapy and the outcome:

Drug History

Do you participate in any counseling or other forms of therapy or support groups? If so, please provide details:

Drug History

Do you have a sex or porn addiction? *

Drug History

Do you have a video game addiction?

Drug History

Do you have an eating disorder?

Drug History

Please describe your plans for aftercare. List any aftercare options which appeal to you: *

Drug History

Abdominal Pain

Angina Pectoris

Arteriosclerosis

Back Problems

Celiac Disease

Chronic Abdominal Pain

Chronic Inflammation

Diabetes Type 1

Endometriosis

Gynecological Problems

Heart Arrhythmia

Hepatitis A

High Cholesterol

Irregular Pulse

Kidney Stones

Migraines

Numbness

Palsy

Seizures

Shaking

Stomach Problems

Thyroid Low

Ulcer

Venous Insufficiency

Abscess

Ankle Feet or Leg Swelling

Blackouts

Bleeding

Cerebellar Dysfunction

Chronic Diarrhea

Cluster Headaches

Diabetes Type 2

Epilepsy

Headaches

Heart Disease

Hepatitis B

History of Heart Attack

Irritable Bowel Syndrome

Liver Disease

Muscle Pain

Obesity

Peptic Ulcer

Severe Cough

Shortness of Breath

Stroke

Thyroid High

Urinary Infection

Venous Thrombosis

AIDS

Arrhythmia

Bradycardia

Blood Clots

Chest Pain

Chronic Fainting

Coronary Artery Disease

Dizzy Spells

Eye Pain

Heart Irregularities

Hepatitis C

HIV

Hypotension Untreated

Joint Pain

Lung or Respiratory Disease

Myocardial Infarction

Painful or Excessive Menstruation

Pericarditis

Severe Headaches

Skin Infection

Tachycardia

Tuberculosis

Varicose Veins

Other

Alcoholic Cardiomyopathy

Asthma

Bronchitis

Cancer

Chrohns Disease

Chronic Fatigue

Delirium Tremens

Emphysema

Faintness

Heartburn

Heart Murmur

Infections

Inflammatory Bowel Diseas

Kidney Disease

Magnesium Deficiency

Nerve Damage

Palpitations

Prolonged QT Syndrome

Sexually Transmitted Disease

Staph Infection

Tremors

Tumor

Vascular Disease

If you answered yes to any of the preceding questions, please provide details here: *

Medical History

Do you or your family have any history of cardiac abnormalities, heart attack or stroke? If so, please provide details. *

Medical History

Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If so, Please provide details.

Medical History

Please list any medications you are presently taking or have taken in the past 6 months. Please list amount or dosage and how often (Please include all medications whether they are prescribed to you or not): *

Medical History

Are you taking any steroids or hormones such as HGH (Human Growth Hormone)? If so, please list amount or doseage and how often: *

Medical History

Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking. Please list amount or dosage and how often. *

Medical History

Please list any depo injections or other injections that you have been given recently or regularly: *

Medical History

Do you have a chronic pain issue? If so, please describe (Please tell us about the source of your pain and what you do to manage it): *

Medical History

Please list all prior surgeries or operations including dates: *

Medical History

Do you have any allergies to foods, medications, herbs or drugs? If so, please describe: *

Medical History

Have you ever been diagnosed with or do you have any psychiatric conditions? Please describe eg. Borderline Personality Disorder, Bi Polar Disorder, Major Depression, Uncontrollable Anxiety, Obsessive-Compulsive Disorder, Schizophrenia, Panic Disorder *

Medical History

Are you currently undergoing care for a psychiatric condition? Please describe (If yes, please also list any medications you are taking for this): *

Medical History

Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)? *

Medical History

Have you ever had a Holter monitor heart test (A heart test where you wear a monitor for 24 hours)? *

Medical Hisorty

Have you taken Suboxone/Subutex in the last 30 Days *

Metabolism

Have you taken Methadone in the last 30 Days *

Metabolism

Have you taken any Benzodiazepines in the last 30 days? If Yes, please provide the (Name, Dosage & How long have you used it for) *

Metabolism

When taking substances do you find you usually need more or less than most people do for an effect from a regular dose?

Metabolism

Have you ever taken a substance/drug that had little or no effect? If so please describe.

Metabolism

Have you ever had an adverse or allergic reaction to any medications or drugs? If so please describe what it was and the dosage/s taken. *

Metabolism

Are you HIV Positive *

Metabolism

If you are HIV Positive, Are you using Anti-Viral Medication *

Metabolism

Please describe any goals you have, what kinds of things motivate you in your recovery? *

Tell us about yourself

Please describe what you do in your career, work or study: *

Tell us about yourself

Please describe what your social support network is like (such as family, friends, co-workers): *

Tell us about yourself

Do you have any spiritual practices or beliefs? *

Tell us about yourself

Please describe your living environment, do you consider it to be healthy or unhealthy? *

Tell us about yourself

Please describe your eating habits and your relationship to nutrition:

Tell us about yourself

Do you feel like you could use some counseling in learning more about nutrition? *

Tell us about yourself

Are you a vegetarian? *

Tell us about yourself

Have you ever taken a psychedelic or entheogen? If so, please describe: *

Tell us about yourself

If so, have you had any negative experiences or reactions to these? Please describe: *

Tell us about yourself

Please tell us what your intentions and/or expectations are for your ibogaine therapy: *

Intentions

Is there anything else you would like to tell us about yourself? *

Intentions

I hereby declare that the information provided is true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.

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