Pre-Screening Questionnaire Tour Agenda

CITY

Netherlands 3 day retreat 8-10 March

Name*

First Last

Email*

Phone

Birth Date*

Have you ever taken part in an Ayahuasca ceremony before?*

Yes
No

If yes, how many times have you drank Ayahuasca? And how did you experience these ceremonies?

Please share, in a couple of sentences, your personal reasons and intentions for entering this Ayahuasca retreat.*

Our workshop will be given in the English language. Do you speak English?

Yes
No

Medical Information

Please select any physical health conditions you are experiencing right now or have experienced in the past:

Please list any other physical health condition not listed above.

Please tell us, in your own words, about your current and past health situation. What conditions play a part in your life? How long has it been that way? Have you had serious health issues in the past?*

Have you ever had major surgery of any kind? If yes, what kind of surgery and when did it take place?*

Psychological / psychiatric information

Please select any conditions you are experiencing right now or have experienced in the past:*

Please list any other psychological/psychiatric information not listed above.

Have you ever been hospitalized or received treatment/therapy for one of the above conditions?*

Yes
No

Would you be in agreement to have us speak to your therapist? If so, please let us know their area of practice and contact information.

Are you currently taking or have you ever been prescribed any medications for these condition(s)?*

Yes
No

If yes, please describe your medication use.

Is there any history in your immediate family of the psychological/psychiatric conditions mentioned above? If yes, Please provide more information. What conditions effects/effected which family members.*

Trauma

Have you ever experienced a serious physical trauma? If yes please tell us more about this.*

Did you have a difficult birth? (This might seem a strange question but people often relive a (traumatic) birth during an Ayahuasca ceremony.) If yes please tell us about your birth.*

Are you aware of any sexual, psychical or emotional abuse in your past? If yes, can you tell us more about this?*

Addiction and Drug Use

How many alcoholic drinks do you normally consume each week?*

None
1-4
5-7
8+

Have you ever been diagnosed, treated, or self-identified as an alcoholic?*

Yes
No

Have you ever used street- or recreational drugs (including Marijuana)?*

Yes
No

If yes, which drugs? How often have you used them and how long ago was this?

Have you ever been diagnosed with, or treated for a drug or addiction?*

Yes
No

Please list any other addictions you have had or currently have.

Medication

Are you allergic to any medication?*

Yes
No

If yes, which medications?

Are you currently taking or have you recently stopped taking (within the last month) antidepressants?*

For more information on anti-depressants please read our Medication Policy

Yes
No

If yes, which anti-depressants?

Aside from antidepressant medications, are you currently taking or have you recently stopped taking (within the past two months) any other prescription medications?*

Yes
No

If yes, which medications?

Are you currently taking or have you recently stopped taking (within the past month) any natural supplements, herbal medicines, or vitamins (including St. John wort, 5-HTP, Kava etc.)?*

Yes
No

If yes, please list the names.

Is there anything additional regarding your health history that you feel we should know?*

Agreements

I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least two weeks prior to coming to Pachamama Temple. I understand that these are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined.*

I agree

I understand that Pachamama staff may require me to take a drug or breathalyzer test prior to or during a retreat, without prior notice or reason. If I refuse to comply with the test or the results come back positive I may be denied entry to the retreat, or be expelled from the retreat immediately. In this case I will not be eligible for a refund.*

I agree

I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca.*

I agree

I testify that I am at least 18 years old.*

I agree

I have read, understand and will comply with the Pachamama Medical guidelines and Medication policy.*

View our policies and guidelines here.