Medical & Psychological Questionnaire Personal Information Full name* Birth Date* Phone* Email* Current Country of Residence* Physical Health History General Health How would you describe your overall physical health?* Do you have any chronic medical conditions?* Have you had any major surgeries in the past 5 years?* Cardiovascular Health Do you have a history of: High Blood Pressureyes Heart Diseaseyes Irregular Heartbeatyes Stroke or mini-strokeyes Chest pain during exertionyes Are you currently on Blood Pressure medication?yes When was your blood pressure last checked?* Neurological Have you ever had a seizure?yes Do you have a seizure disorder or epilepsy?yes History of traumatic brain injury or concussionyes Pregnancy Are you currently pregnant?yes Are you trying to become pregnant?yes Medications & Supplements Please list all current medications, including dosage and frequency Prescription medications Over-the-counter medications Supplements or herbal medicines Important Have you taken SSRIs, SNRIs, MAOIs, antipsychotics, mood stabilizers, or benzodiazepines in the last 6 months?yes Have you recently discontinued any psychiatric medication? If so, when and how was it tapered?yes Psychological Psychiatric History Diagnosis History Have you ever been diagnosed with: Depressionyes Anxiety disorderyes PTSDyes Bipolar disorderyes Borderline personality disorderyes Schizophrenia or schizoaffective disorderyes Psychosisyes Dissociative desorderyes If yes to any please explain Mania / Psychosis Screening Have you ever experienced a manic episode?yes Have you ever experienced psychosis (hallucinations, delusions, loss of contact with reality)yes Hospitalization & Crisis Have you ever been psychiatrically hospitalized?yes Have you ever attempted suicide?yes Have you experienced suicidal thoughts in the past year?yes Substance Use History How often do you drink alcohol?* Do you use cannabis? Frequency? History of stimulant misuse (cocaine, meth, ADHD medication misuse)? History of opioid misuse? History of misuse of other recreational substances? When was your last use of any recreational substance? Trauma & Support Do you have a history of significant trauma?yes Are you currently in therapy?yes Do you have a support system for integration after ceremony?yes Ceremony Readiness & Intention What is your intention for participating in ceremony?* What are you hoping to heal, explore, or understand?* Are you currently in a major life transition or crisis?* What does emotional stability look like for you right now?* Informed Responsibility Please read and acknowledge: I understand that certain medical and psychiatric conditions may make medicine work unsafe for me.*yes I understand that withholding information may put me at risk.*yes I confirm that all information provided is truthful and complete to the best of my knowledge.*yes Signature* Date* Submit
