Download Health history questionnaire

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: