Questionaire

To participate in an Ayahuasca ceremony we need to know some information about yourself. Please answer the following questions as honestly as possible.

What dates do you wish to participate?

First name

Last name

Date of Birth

Phone

History of diseases or pathologies. Especially linked to the liver (hepatitis, fatty liver, etc.) stomach (ulcers, heartburn, gastritis, etc.) or heart.

History of illnesses linked to the mind (depression, trauma, anxiety, panic, etc.)

Use of medications, types, quantity and frequency.

Drugs, dependencies and addictions. Use, frequency and quantity of addictive substances (alcohol, chemical drugs, marijuana, etc.) pathological gambling, etc.

covid vaccines - quantity, adverse side effects

What attracts you to this type of process with Amazonian plants?

Thanks for submitting!

LA MUSA VERDE

Ayahuasca Healing Center

Questionaire