STEP 1

DIETA GUIDELINES

STEP 2

MEDICAL INTAKE FORM

PLEASE READ EACH QUESTION CAREFULLY AND FILL OUT ALL THE SECTIONS BEFORE SUBMITTING YOUR MEDICAL INTAKE FORM.

AT FINCA MIA WE TAKE YOUR PRIVACY SERIOUSLY, WE STORE ALL DATA SECURELY AND WILL NEVER SHARE IT WITH ANYONE.

IF YOU HAVE ANY QUESTIONS ABOUT THE FORM OR THE QUESTIONS HERE, PLEASE REACH OUT TO INFO@FINCMIA.COM AND WE WILL BE HAPPY TO SUPPORT YOU.

ONCE YOU START TO FILL OUT THIS FORM IT IS NOT POSSIBLE TO SAVE YOUR PROGRESS AND COME BACK. PLEASE PUT TIME ASIDE TO CAREFULLY FILL IT OUT IN ONE GO.

MEDICAL SCREENING

Please fill out the following form, answering all questions as accurately as possible

First Name

Last Name

Phone

Address

Date of Birth

Gender

Male

Female

Non Bianary

Other

How are we connected?

Is this your first time with this type of work?

Yes

EMERGENCY CONTACT INFORMATION

Emergency Contact: Name, Number & Relationship

Is your emergency contact aware of your participation with these plant medicines?

Yes

This ceremony is not appropriate for persons with certain medical conditions or for persons using certain medications. It is not recommended for people with cardiovascular problems, serious hypertension, psychiatric conditions, recent fractures or surgery, acute infectious diseases, or epilepsy. For more information about the plant medicines, please visit www.iceers.org. If you have any doubt as to whether you should participate in the session, it is essential that you consult your doctor or therapist. We realize that these questions may be sensitive. It is important for us to know the extent and severity of these experiences so we can support you in the best way possible during your work with the medicine. PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE. YOUR RESPONSES WILL REMAIN STRICTLY CONFIDENTIAL.

I agree to answer these questions honestly and correctly to the best of my knowledge

MEDICAL INFORMATION

Do you have any ALLERGIES?

Yes

If you answered 'Yes' to having allergies, please share more details and specific information about which allergens.

Do you have any FOOD ALLERGIES?

Yes

If you answered 'Yes' to having food allergies, please share more details and specific information about which allergens.

Do you have any FOOD INTOLERANCES?

Yes

If you answered 'Yes' to having food intolerances, please share more details and specific information about which foods you are intolerant to.

If you answered 'Other' above, please share the details of your health condition

If you answered above as having or have had in the past any of the health conditions listed, please elaborate in as much detail as possible

Are you currently pregnant or breastfeeding?

Yes

Have you ever been hospitalized for psychiatric reasons?

Yes

If you answered 'Yes' above, please share more details

If you answered 'Other' above, please elaborate in as much detail as possible

If you answered above as having or have had in the past any mental illnesses, please elaborate in as much detail as possible

Have you ever attempted suicide, had suicidal thoughts, or self-harm?

Yes

Other

If you answered 'Other' above, please elaborate in as much detail as possible

IF you ever attempted suicide, had suicidal thoughts, or self-harm please elaborate

SSRI MEDICATIONS

Please list any SSRI medications you are currently taking and/or have taken over the past 3 months.

Such as:

Prozac, Zoloft, Paxil, Lexapro, Celexa
SNRIs like Effexor or Cymbalta
Medications that raise dopamine like Wellbutrin, or amphetamines.

This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation

Please include:

Dosage
Frequency
For which reason they were prescribed. Ie: sleep, anxiety, psychosis, thyroid, seizures, etc.

If you have stopped taking this medication please state the date of the last dosage, and if you weaned off or stopped abruptly.

Check here if you are currently not taking or have not taken in the last 3 months any of the medications or similar listed above

OTHER MEDICATIONS

Please list any other medications, prescription or over-the-counter, you are currently taking and/or have taken over the past 3 months.

Including: antihistamines, decongestants, opiates and cough medicines.

This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.

Please include:

Dosage
Frequency
For which reason they were prescribed. Ie: sleep, anxiety, psychosis, thyroid, seizures, etc.

If you have stopped taking this medication please state the date of the last dosage, and if you weaned off or stopped abruptly.

Check here if you are currently not taking or have not taken in the last 3 months any of the medications or similar listed above

NATURAL MEDICATIONS, SUPPLEMENTS, RECREATIONAL SUBSTANCES, PLANT MEDICINES

Please list any supplements, recreational substances, or plant medicines that you have taken over the past 3 months

Eg. Alcohol, marijuana, MDMA, cocaine, heroin, ketamine, phenibut, pharmaceutical medications, kava, 5MeO-DMT, bufo, Kambo, kratom, LSD, psilocybin, St John's wart, ephedra, other alternative medicines.

Please Include:

Dosage
Frequency
Last time taken.

This list is not inclusive of all meds in these categories. So listing any medications you have been taking is important for us to make a complete and thorough evaluation.

Check here if you are currently not taking or have not taken in the last 3 months any of the medications, substances or similar listed above

Is there anything else we should know about before you join the Song Circle?

Identificaiton Number

Date

Sign Here

I hereby confirm that I have answered all the questions completely and honestly and have not withheld any information. The information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the ceremony and in meeting my needs throughout. My general health, as far as I am aware, is good. *

I accept terms & conditions

CLICK SUBMIT TO COMPLETE ALL INFORMATION

STEP 1

DIETA GUIDELINES

STEP 2

MEDICAL INTAKE FORM