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| Please provide a brief history of your addiction: |
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| List medications you are taking and daily dosages: |
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Please pay special attention to anti-depressants, anti-anxiety medications, benzodiazepines, and QT prolonging medications. |
| Please provide a complete list of all non-prescribed medications and/or street drugs you are currently using: |
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| Please provide a complete list of all medications you are prescribed, but are not currently taking: |
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| What is your drug of choice? |
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| Please list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month: |
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| Please list all foods and/or medications you are allergic to: |
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| Please list any major surgeries you’ve had in the past, including the date and reason for the procedure: |
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| Are you suffering any emotional or mental conditions? |
Yes No |
Check all that apply:
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| What is your blood pressure? |
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| What is your pulse rate? |
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| What do you hope to achieve from our Ibogaine treatment? |
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| How did you hear about us? |
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| Do you drink alcohol? |
Yes No |
| If yes, how much do you drink, and how often? |
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| Have you ever admitted to a psychiatric hospital? |
Yes No |
| If yes, please explain: |
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| Do you have hypertension or hypotension? |
Yes No |
| If so, what medications are you taking: |
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| Do you have a history of myocardial infarction or heart disease? |
Yes No |
| If yes, please explain: |
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| Do you have a history of seizure? |
Yes No |
| If so, what medications are you taking: |
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| Do you have history of vascular disease including aneurysms? |
Yes No |
| If so, how is it being treated? |
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| Do you have a history of embolism, problems with blood clotting, or recent trauma to the body including the pelvis and legs? |
Yes No |
| If yes, please explain: |
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| Do you have diabetes? |
Yes No |
| If yes, are you insulin dependent? |
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| Do you have hypoglycemia? |
Yes No |
| If yes please explain: |
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| Do you have fainting spells or get dizzy when getting up suddenly? |
Yes No |
| If yes please explain: |
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| Have you ever had surgery to your gastrointestinal tract or have a history of disease including ulcerative coitis, Crohn'ʹs, bleeding, peptic ulcer, etc.? |
Yes No |
| If yes please explain: |
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| Do you have any type of hepatitis including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonia levels, etc.? |
Yes No |
| If yes please explain: |
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| Do you get nauseous easily? |
Yes No |
| If so, what triggers this reaction? |
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| Have you ever coughed up or vomited blood? |
Yes No |
| If yes please explain: |
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| Do you have insomnia? |
Yes No |
| If yes please explain: |
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| Do you consider yourself to be severely depressed? |
Yes No |
| If yes please explain: |
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| Have you ever tried to commit suicide? |
Yes No |
| If yes please explain: |
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| Do you have any type of brain damage including traumatic or closed head injury with or without unconsciousness, or seizure? |
Yes No |
| If yes please explain: |
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| Are you a smoker? |
Yes No |
| If so, how much and how long? |
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| Are you asthmatic? |
Yes No |
| If so, do you use an inhaler? |
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| Do you suffer from any of the following physical conditions? |
Yes No |
