MEDICAL FORM KAMBO

WIEN

For certain diseases or medications, it is extremely important that I am informed in advance to adjust the treatment
accordingly or point out what needs to be considered in connection with Kambo. Please fill in and send it as soon
as possible to: michael@kambo.wien . All information is kept strictly confidential.

29 +38972422856 sarita.yasmin@gmail.com
________________________________
Sarita Castillo ___ ___________________ ____________________

First and last name Age Phone number Email

Yes No

1 Do you take regular medications (also homeopathic or natural remedies)?

X
If yes, please specify the name and dosage below

2 Are you, or have you been pregnant in the last 12 months? X

3 Did you ever had a heart disease? X

4 Did you ever had any liver or kidney disease? X

5 Have you ever had a seizure (asthma, stroke, epileptic seizure, etc.)? X

6 Have you ever had an anxiety-, eating disorder or phobia? X

7 Have you had surgery or serious injury recently? X

8 Do you have diabetes? X

9 Have you ever been diagnosed with any neurological or mental illness? X

10 Do you regularly consume alcohol or other drugs? X

11 Have you ever been diagnosed with a disease that you have not yet named? X

12 Should I know anything else about your physical or mental condition? X

If you have answered „yes“ to one or more questions, please explain here or elaborate on a separate sheet:

There are some people who are not able to take Kambo !

The main contraindications are if someone

• have serious heart problems or is on medication for low blood pressure

• have Addison’s Disease, an aneurism or blood clots
• have had a stroke, a brain hemorrhage or an organ transplantation
• had serious mental health problems (excluding depression, PTSD and anxiety)
• Is undergoing chemo- or radiotherapy, until 6 weeks afterwards
• is pregnant or maybe so, or are breast-feeding a child under 6 months
• have current and severe epilepsy
• is recovering from a major surgical procedure until wounds are healed completely
• had colonic, enema, liver flush, or any water-based detox within 3 days before
• has consumed Iboga or 5-Meo-DMT within the last 6weeks
• has consumed synthetic cannaboids or research chemicals (Spice, Mephedrone, Bath salts,etc.) within 30 days before
• has taken substances like Desmorphine, Fentanyl, U-47700 or Heroin substitutes
• is under the age of 18

Do not drink excessive amounts of liquid prior to the Kambo treatment!

I hereby confirm that I have read and understood the above information, and have answered all questions completely
and honestly, and have not withheld any information

Budapest, Hungary 09/09/19 Sarita Castillo

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