Dieta Intake Form

The information you provide will be reviewed within a few days. If you are taking a substance that is contraindicated, you will be contacted to discuss alternative options. You will need to discuss with your personal physician whether it is safe to stop or suspend taking any supplements or medications before, during, and/ or after the dieta. Any decision to stop taking any of your current supplements or medications must be made in consultation with a trained medical professional. You are fully responsible for any decision you make to stop taking these supplements or medications. It is for your safety, and the safety of all participants, that we require your full disclosure on this form. Thank you.

Full Name

Email address

Primary Contact Number

Date of Birth

Nationality

Occupation

Emergency Contact Name

Emergency Contact Number

Do you have any medical conditions? If so, please list & explain.

Are you currently taking any medications? If so, please list:

Do you have any cardiovascular disease, including heart attacks and strokes?

Do you have any blood pressure conditions (high or low blood pressure)?

Have you had any recent surgery? If so, please explain:

Do you have any significant past or current physical injuries, including fractures or dislocations?

Do you currently suffer from any infectious or contagious disease?

Do you have an Allergy? Or have you ever had a severe allergic reaction?

Do you suffer from Asthma? If so, when is the last time you used an inhaler?

Do you suffer from Epilepsy? If so, when is the last time you had an attack?

Have you been hospitalized in the last 20 years for medical reasons? If so, please explain:

Do you have any dietary requirements? (vegetarian or lactose intolerant. etc)

Are you pregnant?

Have you ever been to a psychologist for any of the following diseases? Schizophrenia, Schizoaffective disorder, Brief psychotic disorder, Delusional disorder, Borderline, Bipolar psychosis, Substance-induced psychosis. If so, please elaborate:

Have you ever taken or are you currently taking antidepressants or antipsychotics? If so, please state and when you stopped with using this medication?

Do you ever hear any voices or sounds that others do not?

Have you ever attempted suicide or had suicidal thoughts? If so please elaborate:

Do you follow or did you follow therapy in your life? If so, please list:

Do you have experience with modified states of consciousness? If yes, please explain:

Do you have experience with use of psychotropic plants such as San Pedro, Peyote, Ayahuasca, Mushrooms, etc.? How often? If yes, please explain.:

Have you experienced side effects or have you had very difficult experiences that may not integrate with psychoactive substances?

Do you practice meditation, yoga, reiki, bioenergy or any other form of self-exploration? If yes, please explain:

If there is anything else that was not addressed in this questionnaire that maybe relevant to know, please describe here:

Have you in the past or do you use any non-prescription drugs, (ie marijuana, cocaine, amphetamines, etc.) If so please list and the reason and frequency of use:

Do you use alcohol? If so, how much per week?

Have you ever undergone a traditional plant dieta (not ayahuasca pre-diet) under the supervision of a shamanic practioner? If YES, please identify the practioner and the plants dieted. How would you describe experience and how you've felt about it since completing the dieta(s). If NO, please type NO.

How did you hear about me and the dieting process?

Is there anything else about your physical or emotional condition that should be considered?

Why you would like to diet plants and what do you hope to gain out the experience:

Your information will be encrypted.

The information you provide will be reviewed within a few days. If you are taking a substance that is contraindicated, you will be contacted to discuss alternative options. You will need to discuss with your personal physician whether it is safe to stop or suspend taking any supplements or medications before, during, and/ or after the dieta. Any decision to stop taking any of your current supplements or medications must be made in consultation with a trained medical professional. You are fully responsible for any decision you make to stop taking these supplements or medications. It is for your safety, and the safety of all participants, that we require your full disclosure on this form. Thank you.