Medical Questionnaire

Medical Questionnaire

If you have any questions, please call us at +51 929 522 040 or email info@naturaliaretreat.com
Name*

First NameLast Name
Gender*
E-mail*
Mobile number*
Date of birth*

DayMonthYear
Emergency Contact*

RelationNamePhone NumberEmail
Have you had any injuries or accidents?*
If yes, please specify:
Have you already participated to an Ayahuasca ceremony in the past?*
Do you follow a specific diet?*
Other diet or diet specification:

Do you have any of the following:*

If you answered yes to any on the above, please specify the causes (for allergies, asthma, depression), and if you are taking/ took any prescription due any condition
Beside of the above, do you take any medication or tablets?*
If yes, please mention the type and the consumption frequency:
Did/do you consume any type of drug?*
If yes, please mention the type and the consumption frequency:
Do you drink alcohol?*
If yes, please mention an average quantity and frequency:
Do you have any comments or special requests?
Terms and Conditions*

By submitting this form , I certify that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.
Should be Empty: