Apoya Palm Center Secoya Medicine Gatherings            

                                     Prescreening Questionnaire

​

Please take your time and fill this form out to the best of you knowledge

It is necessary that you agree to disclose, in confidence, any known medical conditions and/or use of any medication, at the time of booking.

Someone from Apoya Palm Center will contact you once we receive this form and schedule a phone call to discuss things further

​

​

Full Name:

 

Email:

 

Phone Number:

 

Emergency Contact:

 

Emergency Contact #:

 

Age:      Occupation: 

 

What dates will you be attending? 

 

What is your reason for coming? 

 

 

 

 

Is this your first time drinking ayahuasca / yagé?

Yes/ No

If yes please describe your experience working with these medicines:

 

 

 

 

 

 

 

 

Are you allergic to any foods, medication etc?

 

 

 

 

Are you Vegetarian or Vegan?

 

 

 

Have you ever had / or are currently experiencing any of the following medical conditions (Please select all that apply): 

Low Blood Pressure                         High Blood Pressure 

Heart Attack                                  Heart Surgery 

Irregular Heartbeat                         Circulatory Problems 

Angina/Chest Pain                        Heart Murmur 

Seizures (epileptic)                         Aneurysm 

Diabetes/Pre-diabetes                    Meningitis 

Migraines                                    Chronic Pain 

Asthma                                        Cranial Trauma 

Stroke                                          Obesity                                     

Cluster Headaches                        Cancer/Tumor                               

HIV/AIDS                                    Stomach Ulcers

Asthma                                        Tuberculosis                                                                              

Cranial Trauma                              Infectious Disease

Neurological Disease                     Physical Disability 

 

 

 

 

 

Have you ever had / or are currently experiencing any of the following mental conditions (Please select all that apply): 

Schizophrenia                          Clinical Depression

Suicidal Tendency                     Post Traumatic Stress (PTSD) 

Psychosis                                 Bipolar disorder

Eating Disorder                         Chronic Anxiety

Autism                                     OCD

Borderline Personality Disorder     Obsessive Compulsive Disorder 

Depersonalization                      Multiple Personality Disorder 

 

PLEASE ANSWER THE FOLLOWING QUESTIONS BELOW: 

 

Do you have any health issues that you want us to be aware of?
(please list all, including any physical, mental, past injuries or traumas and their history) 

 

​

 

 

 

 

Have you ever been diagnosed, treated or self-diagnosed as an alcoholic or drug-addict?

Yes/ No

If so, please write a brief paragraph about any substances which you may have used or are currently using, how often you would use and your perceived relationship to them. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list any pharmaceutical medications you are currently taking, or have taken within the past 6 months

 

 

 

 

 

 

 

Are you currently taking, or have you recently stopped taking any form of antidepressants? If so, please write the name(s), dosage(s), duration and the date(s) you stopped. 

 

 

​

 

 

 

 

Have you recently stopped taking (within the past month) any natural supplements, herbal medicines or vitamins including St. John Wort, 5-HTP, SAM-e, Kava, Passion Flower, Lemon Balm etc?
If so, please list. 

 

 

 

 

 

 

 

 

 

AGREEMENT: 

I have fully read and understood the contraindications and potential implications of using certain pharmaceuticals with MAOI's. I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least three weeks prior to coming to a retreat at Apoya Palm Center. I understand that these are strongly contraindicated with Yagé and can be very dangerous and potentially fatal when combined. 

I have completed this questionnaire truthfully and have not withheld or misrepresented any information. I agree, to inform the organizer of this retreat if any new information arises that will affect or change this application. 

I release the facilitator, organizer and any/all people associated with Apoya Palm Center from all actions, claims, demands or damages that may result from my participation. 

I will arrive on time and stay until formal closure of the retreat. 

 

I agree                        I disagree 

 

INITIAL:                     Date: 

 

Signature: