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Home
Retreats
Gallery
Client Information Form
The Good Life Project
Contact Us
Professional Team
Client Information Form
Client Information Form
Patient Personal Details
Emergency Contact Information
Drug History
Medical History
Metabolism
Tell us more about yourself
Intentions
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Patient First Name
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Personal Details
Patient Surname
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Personal Details
Address
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Personal Details
City
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Personal Details
Province or State
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Personal Details
Postal/Zip Code
Personal Details
Country
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Personal Details
Passport / ID Number
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Personal Details
Phone
Personel Details
Cell
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Personal Details
Email
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Personal Details
Skype
Personal Details
Weight
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Personal Details
Height
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Personal Details
Date of Birth
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Personal Details
Marital Status
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Personal Details
Dependants
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Personal Details
Primary Physician Name
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Personal Details
Physician Phone
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Personal Details
Health Insurance
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Personal Details
Health Insurance Information
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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
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Emergency Contact Information
Relationship
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Emergency Contact Information
Address
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Emergancy Contact Information
City
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Emergency Contact Information
Province or State
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Emergency Contact Information
Phone
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Emergency Contact Information
Cell
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Emergency Contact Information
Email
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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:
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Drug History
Are any of these substances prescribed to you by a doctor or therapist? If so please provide details:
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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):
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Drug History
Do you drink alcohol? (If yes, please provide details below when asked about other substances that you use)
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Drug History
Do you smoke tobacco?
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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.)
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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):
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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):
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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:
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Drug History
Have you had Oral or Implant Naltraxone in the last 60 Days
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Drug History
Have you participated in Narcotics Anonymous or Alcoholics Anonymous?
Drug History
Have you ever tried ibogaine therapy before?
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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?
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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:
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Drug History
Abdominal Pain
Abdominal Pain
Angina Pectoris
Angina Pectoris
Arteriosclerosis
Arteriosclerosis
Back Problems
Back Problems
Celiac Disease
Celiac Disease
Chronic Abdominal Pain
Chronic Abdominal Pain
Chronic Inflammation
Chronic Inflammation
Diabetes Type 1
Diabetes Type 1
Endometriosis
Endometriosis
Gynecological Problems
Gynecological Problems
Heart Arrhythmia
Heart Arrhythmia
Hepatitis A
Hepatitis A
High Cholesterol
High Cholesterol
Irregular Pulse
Irregular Pulse
Kidney Stones
Kidney Stones
Migraines
Migraines
Numbness
Numbness
Palsy
Palsy
Seizures
Seizures
Shaking
Shaking
Stomach Problems
Stomach Problems
Thyroid Low
Thyroid Low
Ulcer
Ulcer
Venous Insufficiency
Venous Insufficiency
Abscess
Abscess
Ankle Feet or Leg Swelling
Ankle Feet or Leg Swelling
Blackouts
Blackouts
Bleeding
Bleeding
Cerebellar Dysfunction
Cerebellar Dysfunction
Chronic Diarrhea
Chronic Diarrhea
Cluster Headaches
Cluster Headaches
Diabetes Type 2
Diabetes Type 2
Epilepsy
Epilepsy
Headaches
Headaches
Heart Disease
Heart Disease
Hepatitis B
Hepatitis B
History of Heart Attack
History of Heart Attack
Irritable Bowel Syndrome
Irritable Bowel Syndrome
Liver Disease
Liver Disease
Muscle Pain
Muscle Pain
Obesity
Obesity
Peptic Ulcer
Peptic Ulcer
Severe Cough
Severe Cough
Shortness of Breath
Shortness of Breath
Stroke
Stroke
Thyroid High
Thyroid High
Urinary Infection
Urinary Infection
Venous Thrombosis
Venous Thrombosis
AIDS
AIDS
Arrhythmia
Arrhythmia
Bradycardia
Bradycardia
Blood Clots
Blood Clots
Chest Pain
Chest Pain
Chronic Fainting
Chronic Fainting
Coronary Artery Disease
Coronary Artery Disease
Dizzy Spells
Dizzy Spells
Eye Pain
Eye Pain
Heart Irregularities
Heart Irregularities
Hepatitis C
Hepatitis C
HIV
HIV
Hypotension Untreated
Hypotension Untreated
Joint Pain
Joint Pain
Lung or Respiratory Disease
Lung or Respiratory Disease
Myocardial Infarction
Myocardial Infarction
Painful or Excessive Menstruation
Painful or Excessive Menstruation
Pericarditis
Pericarditis
Severe Headaches
Severe Headaches
Skin Infection
Skin Infection
Tachycardia
Tachycardia
Tuberculosis
Tuberculosis
Varicose Veins
Varicose Veins
Other
Other
Alcoholic Cardiomyopathy
Alcoholic Cardiomyopathy
Asthma
Asthma
Bronchitis
Bronchitis
Cancer
Cancer
Chrohns Disease
Chrohns Disease
Chronic Fatigue
Chronic Fatigue
Delirium Tremens
Delirium Tremens
Emphysema
Emphysema
Faintness
Faintness
Heartburn
Heartburn
Heart Murmur
Heart Murmur
Infections
Infections
Inflammatory Bowel Diseas
Inflammatory Bowel Diseas
Kidney Disease
Kidney Disease
Magnesium Deficiency
Magnesium Deficiency
Nerve Damage
Nerve Damage
Palpitations
Palpitations
Prolonged QT Syndrome
Prolonged QT Syndrome
Sexually Transmitted Disease
Sexually Transmitted Disease
Staph Infection
Staph Infection
Tremors
Tremors
Tumor
Tumor
Vascular Disease
Vascular Disease
If you answered yes to any of the preceding questions, please provide details here:
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Medical History
Do you or your family have any history of cardiac abnormalities, heart attack or stroke? If so, please provide details.
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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):
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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:
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Medical History
Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking. Please list amount or dosage and how often.
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Medical History
Please list any depo injections or other injections that you have been given recently or regularly:
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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):
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Medical History
Please list all prior surgeries or operations including dates:
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Medical History
Do you have any allergies to foods, medications, herbs or drugs? If so, please describe:
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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
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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):
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Medical History
Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)?
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Medical History
Have you ever had a Holter monitor heart test (A heart test where you wear a monitor for 24 hours)?
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Medical Hisorty
Have you taken Suboxone/Subutex in the last 30 Days
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Metabolism
Have you taken Methadone in the last 30 Days
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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)
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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.
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Metabolism
Are you HIV Positive
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Metabolism
If you are HIV Positive, Are you using Anti-Viral Medication
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Metabolism
Please describe any goals you have, what kinds of things motivate you in your recovery?
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Tell us about yourself
Please describe what you do in your career, work or study:
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Tell us about yourself
Please describe what your social support network is like (such as family, friends, co-workers):
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Tell us about yourself
Do you have any spiritual practices or beliefs?
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Tell us about yourself
Please describe your living environment, do you consider it to be healthy or unhealthy?
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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?
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Tell us about yourself
Are you a vegetarian?
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Tell us about yourself
Have you ever taken a psychedelic or entheogen? If so, please describe:
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Tell us about yourself
If so, have you had any negative experiences or reactions to these? Please describe:
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Tell us about yourself
Please tell us what your intentions and/or expectations are for your ibogaine therapy:
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Intentions
Is there anything else you would like to tell us about yourself?
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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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