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Kambo Application

First Name

Last Name

Date Of Birth

Phone

Are you currently taking any medication? *

Yes

Are you currently taking any supplements? *

Yes

Do you have any chronic illness? *

Yes

Do you have any current medical conditions? *

Yes

Have you taken 5meo DMT (Bufo) in the past 6 weeks? *

Yes

Do you or have you in the past suffered from a psychological disorder? *

Yes

Are you currently taking any medication for any psychiatric disorder? *

Yes

Have you experienced seizures or been diagnosed with epilepsy? *

Yes

Do you use stimulants and/or drugs? *

Yes

Do you drink alcohol? *

Yes

Do you have a drug, alcohol or any other addiction? *

Yes

Have you had an operation or surgery of any kind recently? *

Yes

Do you have a cardiovascular problem? *

Yes

Is there anything about your physical/mental state I should know about? *

Yes

Do you have previous experience working with Kambo medicine? *

Yes

Have you ever had a stroke? *

Yes

Have you ever had a brain hemorrhage? *

Yes

Are you recovering from a major surgery? *

Yes

Have you ever had an injury or trauma to the Oesophagus/Esophagus *

Yes

Do you or have you ever had tumors or ulcers in the throat? *

Yes

Do you have a heart condition? *

Yes

Do you have Boerhaave’s Syndrome (spontaneous rupture of the esophagus)? *

Yes

In the past 7 days have you done any water fasting, colonics, liver flushes, sauna's or sweat lodges? *

Yes

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Kambo Application

Working With Kambo

About Us

Contact Us

US 619-565-3043

Info@CasaAyniKambo.com

Disclaimer

We do not claim to treat, cure, or prevent any illness. Kambo is a complementary practice and should not replace medical advice or treatment. Please consult with a healthcare provider if you have any concerns or pre-existing conditions.

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