New Client Intake Form Please answer all the questions to the best of your knowledge. Full disclosure is required for the best overall experience.Once your intake form is submitted, go to the home page and click ‘Book a Session’ to secure your time. Please enable JavaScript in your browser to complete this form.If you have any of the conditions listed below, please check the box. *Only needed for Kambo clientsName *FirstLastBirthday *MM/DD/YYYYPhone *Email *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency ContactsPlease provide the name and phone number of someone you would like us to contact if there were an emergency situation. *Only required for Kambo services.#1 Emergency Contact (Name & Phone Number)#2 Emergency Contact (Name & Phone Number)Medical and Health HistoryIf you have any of the conditions listed below, please check the box. History of aneurysm(s)Active ulcersAddison’s DiseaseHistory of brain hemorrhage(s)History of blood clot(s)Boerhaave’s SyndromeChemotherapy or radiation treatments (6 weeks prior or 6 weeks afterward)Congestive heart diseaseHeart bypass surgeryHeart valve replacement surgeryImplanted cardioverter defibrillatorsEnlarged heartPortal HypertensionHistory of stroke(s)History of low blood pressureCurrently breastfeedingOesophagus/Esophagus varicesOrgan transplantParticipating in water-based detox methods of fasting for 7 days or morePregnantSerious mental health conditions such as Schizophrenia and Dissociative Identity DisorderSevere liver diseaseTumors/Ulcers in the throatUntreated eosinophilic esophagitis*Only needed for Kambo clientsIf you checked any of the boxes above, please give more details on your conditions.List any medications you are taking currently or have taken within the past year.List any supplements you are taking currently or have taken within the past year.List full history of medical conditions, surgeries, and operations, chronic pain, etc. Do you have a diagnosed and/or known cardiovascular condition?YesNoIf yes, please specify. (And please make sure you read through our contraindications list to ensure Kambo is safe for you.)Do you have any fears or phobias?Currently or in the past have you suffered from addiction, emotional, mental and/or psychological disorders (CPTSD, Depression, Addiction, Trauma)? If yes, please specify:What sort of assistance and/or work have supported you to manage these conditions?Are you currently taking medication for any diagnosed/medical psychiatric disorder(s)?YesNoIf yes, please explain current condition, duration, medication using, and dosage:Have you ever been through rehabilitation whether a formal center or specific program for substance abuse?YesNoIf yes, please explain.This information is privileged and confidential. Do you have a history or seizures or epilepsy?YesNoIf yes, please explain your history and any medications your may be taking (dosage and duration).Do you use stimulants, recreational drugs, or plant medicines? Please explain.This information is privileged and confidential. Do you drink alcohol? Please share your frequency and if there is a dependency to alcohol. Is there anything about your physical or mental state I need to be aware of? If yes, please specify:How do you feel you are currently managing your health and well-being? Selected Value: 0 On a scale of 0-10, how do you feel about your state of health? 0 is poor, 10 is excellent. What are you intentions for Kambo/Primal Health Coaching?How did you hear about us?Sign-up to our newsletter?We rarely send emails, but if we have group sessions and events, you would receive an email.Submit
