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| Please provide a brief history of your addiction: | |
| List medications you are taking and daily dosages: | |
| | 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: | |
| Please provide a complete list of all medications you are prescribed, but are not currently taking: | |
| What is your drug of choice? | |
| Please list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month: | |
| Please list all foods and/or medications you are allergic to: | |
| Please list any major surgeries you’ve had in the past, including the date and reason for the procedure: | |
| Are you suffering any emotional or mental conditions? | Yes No |
Check all that apply:
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| What is your blood pressure? | |
| What is your pulse rate? | |
| What do you hope to achieve from our Ibogaine treatment? | |
| 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? | |
| Have you ever admitted to a psychiatric hospital? | Yes No |
| If yes, please explain: | |
| Do you have hypertension or hypotension? | Yes No |
| If so, what medications are you taking: | |
| Do you have a history of myocardial infarction or heart disease? | Yes No |
| If yes, please explain: | |
| Do you have a history of seizure? | Yes No |
| If so, what medications are you taking: | |
| Do you have history of vascular disease including aneurysms? | Yes No |
| If so, how is it being treated? | |
| 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: | |
| Do you have diabetes? | Yes No |
| If yes, are you insulin dependent? | |
| Do you have hypoglycemia? | Yes No |
| If yes please explain: | |
| Do you have fainting spells or get dizzy when getting up suddenly? | Yes No |
| If yes please explain: | |
| 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: | |
| 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: | |
| Do you get nauseous easily? | Yes No |
| If so, what triggers this reaction? | |
| Have you ever coughed up or vomited blood? | Yes No |
| If yes please explain: | |
| Do you have insomnia? | Yes No |
| If yes please explain: | |
| Do you consider yourself to be severely depressed? | Yes No |
| If yes please explain: | |
| Have you ever tried to commit suicide? | Yes No |
| If yes please explain: | |
| 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: | |
| Are you a smoker? | Yes No |
| If so, how much and how long? | |
| 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 |
