Iboga Intake Form - Iboga Therapy

Iboga Intake Form:

Please fill out the entire form below. The fields with the small red asterisk are mandatory to be filled out and the form will not be submitted unless all the information has been filled in. Thank you.

** Once you put an intake form, a file is created and somebody will call you to organize the session.

Name *

First

Last

Date of Arrival

Arrival Info (i.e. means of travel etc.)

Date of Departure

Departure Info (i.e. means of travel etc.)

* Indicates required field

Date of Birth *

Time of Birth *

Place of Birth *

Passport Number *

Contact

Email *

Phone Number *

Address

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name *

Emergency Contact Phone Number *

Most Recent Primary Care Information

Physician's Name

Physician's Phone Number

Address

Line 1

Line 2

City

State

Zip Code

Country

When was your last visit to a doctor's office, medical clinic, or hospital?

When was your last checkup?

What was the issue/problem at that time?

Personal Intention

Please list any ongoing concerns or conditions, when they started, how often they occur, and how severe.

What is your personal intention for your Iboga treatment? Please write in detail. *

Prior Medical History

Please tell us about your prior medical history, if other people in your family have had it, if it is current, and any other important information.

Have you had any hospitalizations or surgeries? If so, please include the dates of such.

Please list any allergies to medications and what type of reactions you may have. *

Are you vegan? Gluten free? Please explain and or list other dietary restrictions. *

Current Medications / Substances

Please list any medications and or substances you are currently taking. Also, please list for each the reason why you are taking or using it, when you started, and by whom it may have been prescribed.

Please list any supplements you are taking as well as the brand, dosage, reason for taking them, when you started, and by whom they may have been recommended by.

Other Healthcare Providers

What prior experiences have you had with healthcare in general?

What prior experiences have you had with alternative therapies? (For Example: colon therapy, massage, liver/gallbladder flush, acupuncture, enema, heavy metal tests, etc.)

General Health

Current weight

Weight one year ago

Height

Does your temperature run warm or cool?

On a scale of 1-10, 10 being maximum wellness, please rate your current level of wellness for the following dropdown boxes:

Mental

Physical

Energy Level

Please tell us what type and how much of the following things you consume in the course of a month:

Soda (oz. per day)

Coffee (oz. per day)

Water (oz. per day)

Gluten (rough estimate)

Artificial Sweetner (# of packets or oz.)

Natural Sweetner

Cookies, Cakes, Muffins

Grains

Chips

Black Tea

Alcohol (drinks per day)

General Food Cravings

Snack Foods

What is Your Typical Breakfast?

Typical Lunch?

Typical Dinner?

Any Other Comments?

Please Tell Us About Your Life

With whom do you live with? Please tell us their name(s), age(s), and relationship(s) to you. *

How did you hear about us? *

Which way would you prefer to consume the Iboga Root Bark. *
Capsules (around 26 capsules)Raw Bark with HoneyAny of the above

What is your occupation?

Do you work full time, part time, student, retired, disability?

Do you take vacations?

How many hours per week do you watch television?

How many hours per week do you read?

Are you currently married, divorced, single, widowed, or other?

Are you lonely, sad, or depressed?

Are you positive?

What countries have you traveled to?

What are the major stressers in your life?

Describe your support network

Have you ever been abused or assaulted in any manner?

How is your sleep?

Do you consider yourself physically healthy?

What do you do to relax?

Tell us about your daily environment, natural, home, or work.

Do you exercise? If so what types of activity and for how long and how often?

Do you smoke tobacco? Past or present use?

Do you use recreational drugs? Which ones? *

Have you ever been treated for drug of alcohol dependence?

Do you follow any dietary restrictions? If so, what kind? *

Do you follow a spiritual practice?

Do you have any hobbies or interests?

Have you had any head injuries?

Motivation

Tell us what is your motivation regarding your healing and level of motivation. *

Are you willing to try alternative health modalities?

What do you expect from your practitioners/guides?

Life Chart

Wellness is a balance of many factors. On a scale of 1-10, 1 being the lowest, please rate each of the following areas of your life in terms of happiness by marking the correct column. A score of 10 would mean that you are very happy with that aspect of your life. Conversely, a score of 1 would indicate that you are very unhappy with this area of your life.

Physical Health

Emotional Health

Financial Health

Family Life

Work Life

Romance/Love Life

Friendships

Spiritual Health

Do you have experience with plant medicine? Please list *

Have you had a Covid vaccination? If so how many times?

Your picture *

Maximum size file: 4MB