Your Health and Lifestyle

This questionnaire is for those who want to take part in the sacred medicine ceremonies (Ayahuasca and Kambo ) and not for general tourists coming for the Rainforest experience.

Please take a moment to answer the following questions honestly and in reasonable detail.
Your responses will remain confidential and help us assess your suitability for a particular program . We may keep this information for up to three months after your last session to support post-retreat evaluation. Your feedback also helps us improve the care we provide.

The purpose of the screening parts are to determine whether plant medicine healing is suitable for you or whether you might require a more bespoke specialist service rather than joining a general group whose principal purpose is for spiritual development. For example, if you are alcohol dependent and wish to be free of that then it might be more appropriate to put you with people with similar problems so that the emphasis of your stay is more specifically orientated to your needs as there are specific techniques/modalities which can be employed in addition to the plant ceremonies.

Plant medicines vary greatly in their intensity and specificity and some entail certain risks. Your answers to this questionnaire will help us to determine which medicinal plants and foods we might use. Additionally, we will normally use either Kinesiology or the Neutral Pendulum technique to see how you are likely to react to the plants to ensure no harm and to optimise results.

Working with ayahuasca can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with cardiovascular problems, serious hypertension, psychiatric conditions, recent fractures or surgery, acute infectious diseases, epilepsy or active spiritual emergencies.

There is no empirical research data on the safety of ayahuasca in pregnant women. If you have any doubt as to whether you should participate in the session, it is essential that you consult the organisers of the session.

Please complete the form below as best you can. If you're unsure about any question, simply enter a question mark (?). If its not applicable write NA .

Participant Information

First name

Last name

Phone

Address

Profession

Date and time of birth

Day

Month

Year

Time

HoursMinutes

Place of birth

Marital Status

Emergency Contact Information

Emergency Contact Name

Relationship To You

Telephone

Home Address

Personal Information

Are you currently pregnant?

YES

Have you ever participated in an Ayahuasca ceremony?

YES

If yes, how many, where and when?

Have you experienced adverse or particularly difficult experiences with ayahuasca that you have found hard to integrate? If yes, please provide details.

Have you experienced adverse or particularly difficult experiences with other psychoactive substances that you have found hard to integrate? If yes, please provide details.

Have you ever undergone a Master Plant Dieta? If YES , please provide details below of the dieta(s), including the date(s), location(s) and a summary of your experience(s).

Medical History

Please describe any physical health conditions that you are currently experiencing or have experienced in the past.

Please describe any surgery requiring a general anaesthetic, including the nature of the surgery, when it took place and your stage of recovery.

Please list any medication you are currently taking or have stopped taking within the last 3 months.

How would you describe your current state of health?

Psychological Information

Ayahuasca ceremonies are a journey of personal growth and are best seen as a complement to and not a replacement for psychotherapy.

You're not alone if you've experienced anxiety or emotional distress; it's incredibly common, especially given the pressures of modern life. Around 20–30% of people face challenges significant enough for a diagnosis, often treated with medication.

So please don’t worry about labels—many of us are navigating similar struggles.

Psychological History

Please click on any of the psychological health conditions from the list below that you, have been diagnosed with previously or are currently experiencing.

Have you ever been hospitalised for any of the above conditions, or received therapy? If so, please describe.

Are you currently receiving therapy or attending any kind of support group? If yes, please describe in detail, including the approach of therapy you have been involved in.

Are you currently taking, or have you ever been prescribed, any medications for these condition(s)? Please specify.

Is there anything else about your physical or emotional state we should know about not previously covered?

Addictions

If so, please tell us more about your addiction(s), when did it start, how serious does it seem, etc.

Medication and Natural Medicine History

Are you allergic to any medication? Please specify

Are you currently taking or have you recently stopped taking anti-depressant medication? Please specify.

Are you currently taking or have you recently stopped taking any other prescription medications? Please specify

Prescribed and Non-Prescribed Drug Interactions with Ayahuasca

If you are currently taking any of the medications listed below—or others in the same category—please speak with your doctor at least three months before your first ceremony. Ask whether it's possible and safe to gradually reduce and stop them, allowing enough time for your body to be free of residual medication.

We understand this can be challenging, especially as many Western doctors may be unfamiliar with or skeptical about Ayahuasca. Since they prescribed the medication, their advice may be predictable. Ultimately, this is your decision and responsibility.

What matters most is your safety. We cannot allow participation if there's a risk of adverse drug interactions. Please take the time to consider your options carefully.

MAOI’s, Cocaine, Amphetamines (meth-, dex-, amphetamine), ephedrine, MDMA (Ecstasy), MDA, MDEA, PMAOpiates (heroin, morphine, codeine, and especially opium), Dextromethorphan (DXM), Nutmeg (at psychoactive levels) 5-Meo-DMT, LSD. Any serotonin precursor Antihypertensives (high blood pressure medicine), appetite suppressants, medicine for asthma, bronchitis, or other breathing problems, antihistamines, medicines for colds, sinus problems, allergies. Any drug containing dextromethorphan/DXMCNS depressants (xanax, ativan, etc), Vasodilators, Antipsychotics Barbiturates.

Marijuana should be stopped at least two weeks prior to the start of your programme and not be resumed for at least two weeks following the last ceremony.

Are you currently taking or have you recently stopped taking any natural supplements, herbal medicines, or vitamins? Please specify.

Personal Background

This section of our application seeks to understand you more as a person.

What are some of the activities that bring you joy and pleasure?

If you have had a difficult experience that you were able to overcome. How did you overcome it?

If there is anything you wish to tell us about yourself please do.

Allergies

Please write down any allergies to medicines, drugs, food, etc.

Do you have any severe or potentially life-threatening allergies that would require the use of an Epi-Pen? Please specify.

What are your diet preferences - please click those applicable.

Omnivore (red meat and fish as a meat source)

Pescatarian (fish only as a meat source)

Vegan (strictly no animal products)

Fruitarian (fruit only)

What do you want to achieve by attending the ceremonies?

Agreement & Informed Consent

I will disclose all prescribed medications and medical treatments or therapy that I am currently taking or undergoing.

I agree.

I will discontinue use of alcohol, marijuana, recreational, street drugs and non- prescribed pharmaceuticals at least 3 weeks prior to commencing. I understand the potential dangers inherent in the Ayahuasca ceremony when drugs are in my system.

I agree

I have completed this questionnaire myself, have answered truthfully, and fully understand that withholding or misrepresenting information could result in serious complications when drinking Ayahuasca. I take full responsibility for myself.

I agree

I have read, understand and will comply with the medical guidelines and Ra Initiative safety policies.

I agree

Signature

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Date

Day

Month

Year

Your Health and Lifestyle

Participant Information

Emergency Contact Information

Personal Information

Medical History

Psychological Information

Psychological History

Addictions

Medication and Natural Medicine History

Personal Background

Agreement & Informed Consent

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