STEP 1

DIETA GUIDELINES

STEP 2

MEDICAL INTAKE FORM

STEP 3

ARRIVAL INFORMATION

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
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Gender
Relationship Status
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EMERGENCY CONTACT INFORMATION

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

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.

MEDICAL INFORMATION

Do you have any allergies?
Do you have a past history of, or currently suffer from, any serious health conditions? Please select all that apply. If a condition is not listed, then select other and type all details in the box that appears.
Are you currently pregnant or breastfeeding?
Have you ever been hospitalized for psychiatric reasons?
Do you have a past history or suffer from any mental illness? Please select all that apply. If a condition is not listed, then select other and type all details in the box that appears.
Have you ever attempted suicide, had suicidal thoughts, or self-harm?

SSRI MEDICATIONS

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

Such as:

  • ProzacZoloftPaxilLexapro, 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.

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.

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.

CLICK SUBMIT TO CONTINUE TO THE

ARRIVAL FORM

STEP 1

DIETA GUIDELINES

STEP 2

MEDICAL INTAKE FORM

STEP 3

ARRIVAL INFORMATION

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