Screening Form | CatherineAdunni

First Name

Last Name

Email Address

Phone

Other

How would you describe your current state of health?

Have you ever undergone major surgery requiring a general anesthetic? If so please provide details of surgery including the ailment, date of operation and any limitations that you are now bound by. *

Other/ None

Are you currently taking, or have you ever been prescribed any medications for these conditions? If so, please name.

Do you have a family history of any of the above psychiatric conditions? If so, please specify which family member(s), which condition(s)

Have you ever been diagnosed, treated, or self-identified with drug addiction? If so, please provide us with some additional information about the type of substances and time span of addiction.

Have you ever experienced addiction to any other substance or activities (eg. work, sex, gambling, pornography etc.) either in the past or the present?

Are you allergic to any foods or medications? If so, please list.

Are you currently taking, or have stopped taking any other prescription medications? If so please specify or type no.

Are you currently taking any natural supplements, vitamins or herbal medicines? If so, please specify.

Do you have any severe or potentially life-threatening allergies that would require the use of an Epi-pen? If yes, specify.

Is there anything concerning your physical and psychological health history that has not been covered by this questionnaire that you would like to share with us?

Have you experienced what you would regard as a traumatic incident in your past that you would like to share with us

Please Describe your current living and work situation; please note if you are studying or working, your profession and describe the home environment that you will be returning to after your time with us. This information is important so as we can do our best to prepare you for returning to your home life after your sacred medicine journey with us.

Did someone refer you? Who?

Emergency Contact Name

Emergency Contact Phone

Screening Questionnaire