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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Date: Treatment Program: IBOGA WELLNESS MEDICAL HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential. If you are unable to check the boxes, please underline or bold the answers. Full disclosure of all information is important for safety purposes. Failure to disclose all information could result in disqualification from treatment. Name: M Marital status: Single Partnered Married Separated Have you had an EKG or Liver Panel Test: Divorced F DOB: Widowed Date of last physical exam: PERSONAL HEALTH HISTORY Check All Current Conditions: Do you suffer from: Sleep Apnea Asthma Heart Condition High Blood Pressure Liver Condition Anxiety Depression Addiction Candida Infection Viral Infection Depersonalization Kidney Condition List any medical problems that other doctors have diagnosed Surgeries Year Reason Hospital Other hospitalizations (including mental health hospitalizations and drug/alcohol treatment programs) Year Reason Have you ever had a blood transfusion? Hospital Yes No List any prescribed, recreational drugs and/or over-the-counter medications (including vitamins, herbs, inhalers…) Name of Drug or Medication Strength Frequency Taken Allergies or Sensitivities to medications or food Name the medication or food Reaction You Had HEALTH HABITS AND OTHER ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE WILL BE KEPT STRICTLY CONFIDENTIAL. Exercise Sedentary (No exercise) Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) Diet Are you dieting? Yes No If yes, are you on a physician prescribed medical diet? Yes No Yes No Are physically addicted to alcohol? Yes No Have you considered stopping? Yes No Have you ever experienced blackouts? Yes No Are you prone to “binge” drinking? Yes No Do you suffer from DTs or shaking if you stop drinking? Yes No Do you use tobacco? Yes No # of meals you eat in an average day? Caffeine Rank salt intake Hi Med Low Rank fat intake Hi Med Low None Coffee Tea Cola # of cups/cans per day? Alcohol Do you drink alcohol? If yes, what kind? How many drinks per week? Tobacco Cigarettes # of years Drugs pks./day Chew - #/day Pipe - #/day Cigars - #/day Or year quit Do you currently use recreational or street drugs? (if yes, please see Drug History section) Yes No Have you ever given yourself street drugs with a needle? Yes No Do you suffer from sexual dysfunction? (low libido, impotence…) Yes No Do you suffer from any STDs? Yes No Yes No Yes No Do you consider yourself physically healthy? Yes No Do you consider yourself mentally healthy? Yes No Do you consider yourself spiritually healthy? Yes No Have you ever taken iboga or ibogaine in the past? Yes No Have you experienced other plant/shamanic medicines in the past? Yes No Yes No Do you suffer from any phobias or OCD? Yes No Do you feel depressed? Yes No Do you suffer from panic attacks? Yes No Do you suffer from PTSD or have had a traumatic childhood? Yes No Have you ever suffered a psychotic break? Yes No Have you ever been or are currently suicidal? (please explain below) Yes No Do you currently or have you ever heard voices? Yes No Do you have an eating disorder? Yes No Are you currently or have you been under the care of a mental health professional? Yes No Sex If yes, please list condition(s): For women, are you currently on prescription birth control? Have you ever been sexually assaulted or abused? Other Do you consider yourself “ready” for a change in your life? MENTAL HEALTH Please explain any mental health condition details and/or any “yes” answers here: DRUG HISTORY Please skip section if you have never taken any street drugs or addictive prescription medications Are you having problems getting off of a drug or medication? Yes No Have you ever taken Suboxone or Methadone in the past? Yes No Are you currently taking any benzodiazepines (Ativan, Xanax, Valium, Klonopin…)? Yes No Are you currently taking a medication for sleep? If yes, list here: Yes No Are you currently taking any ADD/ADHD medication (Adderall, Ritalin, Concerta…)? Yes No Are you currently taking any medications for depression and/or anxiety? Yes No Do you currently smoke marijuana on a regular basis? Yes No Do you currently use cocaine, meth, crack or other major stimulant on a regular basis? Yes No Please list drug(s) that you are addicted to here and the daily dosage: Please explain any yes answers here or any other information we should know: OTHER CONDITIONS Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. Skin Problems Chest/Heart Conditions Cognitive Problems Joint pain Back Pain Weight loss/gain Liver Problems Intestinal Problems Thyroid Conditions Kidney Problems High Blood Pressure Insomnia Chronic Infections Bowel Problems Other: Respiratory Issues Circulation Problems Please explain any yes answers here, or if there is any other information we should know about: Please explain the reason(s) for wanting treatment in one of our programs: