The Medicine Angel

The Medicine Angel

Medical Screening Questionnaire

Medical Screening Questionnaire

Your wellbeing is very important to us and your health and safety during the retreat is our upmost priority.

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Please complete the mandatory health questionnaire form below.

Is this the first time Ayahuasca plant medicine experience for you?
Are you currently taking any medications?
If so, please name them, the dosage, frequency and how long you have been on the medication(s).
Have you been taking any antidepressants within the last 40 days?
If so, please name them, the dosage, frequency and how long you have been on the medication(s).
Do you have any history of heart related concerns?
ie, hypertension (High Blood Pressure, Arrhythmia, Tachycardia, Heart attacks, Heart surgery, stents, shunts etc.
Have you ever experienced a seizure, stroke or been diagnosed as epileptic or diabetic?
If yes, please provide details
Do you or anyone in your immediate family (parents or siblings) have schizophrenia or Bipolar disorder?
If yes, please provide details
The Best Tiny Home Vacation
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Caleb Zanzer
The Best Tiny Home Vacation
“When you are designing with Lorem Ipsum, you diminish the importance of the copy by lowering it to the same level as any other visual element. The text simply becomes another supporting role, serving to make other aspects more. Instead of your design enhancing.”
Marii Brown