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Registration and health intake form

Please take the time to fill out this form as completely as possible. This will help us to get a comprehensive health history so we can support you better.

Choose your Retreat

First Name

Last Name

Address

Age

Your Email

Email newsletter

send me upcoming events

Your Phone Number ( Telegramm )

Emergency name and contact

Medical and preventativ health

Do you see a doctor, psychiatrist or any specialist(s) at the moment?

Allergies

List of food and/or medication(s) you are allergic to and what reaction you have

Current medications

List all medications, including over-the-counter and homeopathic/natural remedies, with dosages and times taken you are currently taking

List all hospitalizations, surgeries and serious accidents

Include year and place treated

Do you have a special diet or food intolerance?

specify

How much coffee/ tea/ cacao do you drink each day?

How much alcohol do you drink/ frequency?

Do you smoke tobacco?

How long have you smoked?

Do you use other substances (marijuhana, psylocibyn, cocain or other drugs)?

If Yes, at which ferquency and quantity (social, microdosing, daily)?

Did you experience any psychological conditions such as: depression, psychoses, paranoia, anxiety, crisis or other? If yes, can you please describe a bit more?

Do you have a major health condition that we should be aware of?

Please list below anything else that is of concern to you or that you feel we should know

Please list your main concerns/ goals for these ceremonies (physical, psychological, emotional, spiritual)

Are you coming with someone?

Yes

If yes, please write the name of the person who you come with

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