Online medical form

Please answer the following questionnaire.We ask you to tell us if you have any disease, pathological or functional problem not considered here.

Name and surname: *req.
E-mail: *req.
Retreat dates: *req.
Country:
Occupation:
Date of birth: (dd-mm-yy)
Sex: Male.
Female.
Marital status:
Languages you speak: English
Spanish

Answer the following questions only if affirmative.
Blank answers meanning NO.

Do you have any disease or special psychological condition? If yes, please, explain.

Are you currently taking any medication? If yes, please, explain.

Do you have any dietetic program? If yes, please, explain.

Psychoactive substances use

Substance Frecuency Last consumption
Cocaine
Crack
Opiaceous (opium, morphine, heroine)
Marihuana / Hashish
Alcohol
Pills
LSD
MDMA (Extacy)
Others

Do you have any experience with modified states of consciousness? If yes, please, explain.

Do you have any experience with ritual context use of psychotropic plants like San Pedro, Peyote, Ayahuasca, Hongos, Wilca, etc? If yes, please, explain.

Do you practice meditation, yoga, reiki, bioenergy or another self-exploration technique? If yes, please, explain.

How do you find us?

Do you have any problem not indicated in this questionnaire? If yes, please, explain.

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