Treatment Application Form at Baja Ibogaine Center, Mexico

Name *

First

Last

Email *

Phone

Cell Phone

Age *

Weight

Height

Emergency Contact

Contact Email And Phone Number

Primary Drug Of Addiction *

Brief history of your addiction or condition you are seeking treatment for *

List of Prescribed Medications: Include daily dosages *

List of medications prescribed, but, not taking *

List of all non-prescribed medications / or street drugs used in the past 30 days. *

List of all supplements / performance enhancers currently taking / or have taken in past month *

List any major surgeries you have had, including approximate date *

List of all foods / medications you are allergic to *

Do You Drink Alcohol? *

Yes
No

If Yes, How Much / How Often

Do You Smoke ? If Yes How Much Daily

Do you have a history of myocardial infarction or heart disease? If Yes, explain *

Do you have hypertension or hypotension?

Yes
No

Do you have a history of seizures?

Yes
No

Do you have a history of vascular disease, including aneurysms?

Yes
No

Do you have a history of embolism, problems w/ blood clotting or recent trauma, including the pelvis or legs? If so, please explain?

Do you have diabetes?

Yes
No

Are you Insulin Dependent ?

Yes
No

Do you have fainting spells or get dizzy upon getting up suddenly? If so, please explain

Parkinson's Disease

Yes
No

Do you have a history of ulcerate colitis, Cronin's Disease, bleeding or peptic ulcers? If yes, please explain

Do you have any type of hepatitis, including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonia levels, etc . . .? If yes, please explain

Do you consider yourself to be depressed? If yes, please explain

Have you ever tried to commit suicide? If yes, please explain

Have you ever been admitted to a psychiatric hospital? If yes, please list approximate dates and condition you were treated for

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Do you have any type of brain damage, including traumatic or closed head injuries w/ or w/o unconsciousness or seizures? If yes, please explain

Are you asthmatic? If yes, do you use an inhaler?

Hepatitis A, B or C

No
C
B
A

Liver Problems

Yes
No

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