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Name *

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What is your occupation? *

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How did you hear about Kambo? *

Have you experienced Kambo before? *

What are some areas in your life that feel blocked or need improvement? *

Do you have allergies or sensitivities? *

Do you have Diabetes, Kidney, Liver, or Addison's disease? *

Have you had a stroke, aneurysm, or bleeding from the brain? *

Are you in advanced stage Lyme disease? *

Do you have epilepsy? *

Have you done any juice fasts or cleanses recently? Any recent colonic or enema treatments? *

Do you have varicose veins treated by medication? *

Do you have any artificial devices in body such as a stint,brain devices, organ/stem cell, or breast implants? *

Do you have asthma and/or breathing problems? *

Are you pregnant or breastfeeding? *

Have you received chemotherapy or radiation within the last 8 weeks? *

Do you have high or low blood pressure? If so, do you take medication for your blood pressure? *

Do you have a history of heart disease, blood clots, or bypass surgery? *

Have you experienced any depression or anxiety, or do you have a family history of these conditions? *

Do you have any current or past health challenges or medical concerns? *

Have you ever tried plant medicines like Ayahuasca, Iboga, Mushrooms, Sananga or Hape? *

Do you have a history of drug abuse or addiction? *

What else would you like for me to know? *

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