Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Contact person, relationship, phone # * Contact person, relationship, phone # * Contact person, relationship, phone # * Please tell us of any health conditions you’d like to address during this medicine retreat: * Do you have any conditions that might affect your ability to sit or lie still? If so please describe. * Have you been diagnosed with any mental/emotional conditions, including psychosis, schizophrenia, bi-polar disorder, manic depression or any other psychiatric condition? If so, please describe. * Have you ever had a seizure and/or been diagnosed with epilepsy? If so please describe. * Are you pregnant? * Do you have any history of heart disease including cardiac failure or stroke? If so, please provide details. * Do you have any history of high blood pressure? If so please describe. * Do you have diabetes? * Do you have asthma? * Please list any allergies you have. If none, write none. * Please list any medications, whether natural or pharmaceutical, self or doctor prescribed or recreational, that you have taken in the last month. Please be thorough. * Have you taken any of the following kinds of medications in the last month? * Antibiotics Allergy medications or Antihistamines (e.g., Benadryl, Claritin SSRIs (e.g., Prozac, Zoloft, Paxil) MAOIs (e.g., Marplan, Nardil, Emsam) Steroids Antihypertensive medications Appetite suppressants (e.g., diet pills) Cold medicines Vasodilators Anti-psychotics Barbiturates Opiates Central Nervous System Depressants none of the above Have you taken any of the following herbs or supplements over the last month? if so, please describe which along with frequency and dosage. L-Tryptophan, Ephedra, Kava, St. John’s wort, Ginseng, Yohimbe, Sinicuichi, Nutmeg, Chinese herbal formulas * Have you had any recent accidents, illnesses, operations or hospitalizations? * Have you had COVID-19 or any of its variants in the past 2 years? If so, when? Have you fully recovered? * Are there any other physical, mental or emotional conditions, which we should know about, and/or which you feel might be relevant to your safe participation in this retreat? * Do you have any other questions? Thank you! 2024 Peru Journeys Health Form