Kambo Quest Intake Questionnaire

Contact/General Information

Legal Name *

Preferred Name (if different)

Pronouns *

Age *

Email *

Phone *

City/State of Residence *

Occupation *

Have you worked with Kambo before? *

No

Yes

Have you worked with plant medicines before? *

No

Yes

What would you like to achieve from your session(s)? *

Health Information

Kambo practitioners around the world have closely observed participants to gather as much information about safe use as possible. There are a few certain contraindications but most situations are taken on a case-by-case basis. Information provided here helps us to build on our knowledge and provide the safest practice possible. Thank you for taking the time to fill out this information honestly and completely.

Medications *

Supplements *

Recreational Drugs *

Alcohol Use *

Allergies *

Sensitivities *

Health problems of concern at this moment *

Previous or chronic health issues *

(chronic fatigue, arthritis, migraines, thyroid conditions, etc)

Please answer “no” or “yes” for each of the following items to show that you have carefully read this list. If you answer“yes” please add details as needed. It’s crucial that you’re truthful in your answers- withholding any information can be harmful or even fatal.

Medications & Surgery *

	No	Yes
Have you stopped taking any medications in the last month?
Have you had surgery recently (include dental surgery)?

Medication/Surgery Details

How often do you exercise? *

Heart Health Details

Neurological & Circulatory Health *

	No	Yes
Do you have epilepsy/seizure disorder?
Have you ever had a brain hemorrhage or stroke?
Have you ever had a blood clot?
Have you ever had an aneurism (weak blood vessels)?
Do you have abnormally high/low blood pressure?
Are you on medication for low blood pressure?

Neurological & Circulatory Health Details

*

	No	Yes
Do you have asthma?
Have you had an anaphylactic reaction to anything? If so, what?
Have you ever had any viral conditions (Lyme, herpes (cold sores), hepatitis, HPV, dengue)?

Please provide details here

*

	No	Yes
Are you taking, or have recently stopped taking, diet/weight loss pills?
Are you taking, or have recently stopped taking, sleeping pills/supplements?
Are you taking medication that contains serotonin?
Have you taken a MAOI type drug or Bufo/5-MEO DMT in the last month?

Please provide details here

*

	No	Yes
History of bulimia or anorexia?
History of alcohol/drug addiction?

Please provide details here

Mental Health History

Please inform me if you have ever, or are currently, experiencing any mental health conditions, regardless of whether or not you are taking medication. If you are on any mental health medication it is of utmost importance for your safety that you accurately report your diagnosis/symptoms and treatment plan. Thank you.

*

	No	Yes
Do you have any history of psychosis?
Do you have any history of admittance to a mental health facility? If yes, why?
Have ever suspected you might be or have you been diagnosed on the Autism spectrum?
Have you been diagnosed with ADHD?
Have you been diagnosed with Borderline Personality Disorder?

Please provide details here

Is there anything else regarding your physical or mental health that you would like to mention?

Kambo Quest Agreement and Risk Waiver

I understand that our session(s) will include the use of traditional folk remedies used by indigenous people for good health. These remedies are collected and prepared in their natural environment; no regulations exist to guarantee their content, purity, or strength. I understand that these remedies are not approved or endorsed by the FDA and are being offered experimentally without implied safety or benefit.

Kambo is applied via superficial burns to the skin – these may permanently scar. Possible (rare) adverse reactions include – hyponatremia (low blood sodium that can lead to brain swelling), esophageal tears, conditions exacerbated by increased blood pressure, injury related to fainting, and others.

To the best of my knowledge, I am in good physical condition and I am not aware of any physical or psychological infirmity that would place me at risk to participate in any way. I have answered the Health Intake Form honestly and been given the opportunity to have my questions answered.

I agree that I am always at choice on whether or not to participate, and I agree to take full responsibility for the choices I make involving this work, both during and after the event/session.

I agree to listen to and follow the instructions given by the facilitators.

Event facilitators reserve the right to ask anyone, at any time, to leave, with no refund, for any reason.

I understand this event/session is intended to be supportive and helpful in nature but is not a substitute for professional physical or mental health care. I am responsible for identifying if my situation also merits the services of a professional. I am responsible for seeking out further support if needed and release facilitators for any liability related to emotional or physical distress.

I agree to participate with the purest intention of heart, promoting the health and well-being of all participants. I will help create a safe and respectful space by holding the identity and experiences of anyone else in session as confidential.

Waiver Of Liability

I agree to release from all liability and waive my right to sue Kambo Quest, J. Troi Kunko/Troi Deluz, the event planners, organizers, facilitators, volunteers, the venue host, property owner or tenant (collectively “Released Parties”) from any claim, loss, liability, damage, or cost to persons or property arising from my attendance or participation in events/sessions, whether caused by the negligence of the released parties, or otherwise. I intend for this release and waiver to extend to my heirs and any other parties acting on my behalf.

Assumption Of The Risk

I assume full responsibility for any risk of bodily injury, illness, psychological damage, death, or property damage to myself, or others, arising from my attendance or participation in this event/session. In the event that any of the released parties are found liable to me, the total liability is limited to my admission fee.

My signature indicates I have read and understand the information provided in the above stated waiver and agree to be bound by this agreement. I sign voluntarily and with intent to execute this waiver for full and complete release of liability.

Name *

Signature

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	No	Yes
Were you born with any heart conditions?
Do you currently have any heart problems?
Have you had major heart surgery?
Can you tolerate aerobic exercise?

	No	Yes
Are you on immune suppressants?
Are you undergoing chemotherapy or radiation, or have you recently?
Have you had any major surgeries?

	No	Yes
Diabetes (Type 1 or 2, using insulin?)
Addison's Disease
Reynaud's Disease
GERD, IBS or Crohn’s
Gastric ulcer or esophageal issues

	No	Yes
Is there any possibility you are pregnant?
Are you nursing a baby under 6 months old?
Are you undergoing fertility treatments?
Are you taking birth control pills?