In order for us to give you the best possible treatment and insure your safety, please fill out the following questionnaire accurately and truthfully. Your answers on this form will help us understand your medical concerns and conditions better.
Best estimates are fine if you cannot remember specific details.

Thank you!

Your Full Name:

WHAT IS YOUR INTEREST IN IBOGAINE?

1) For Spiritual Advancement?
Explain:

2) For treatment of drug addiction/addictions? (Please specify which drug?)
Explain:

SOCIAL HISTORY

SUBSTANCES

Tobacco Use
Cigarettes

Quit? Date?

Never used:

Current: Smoker: packs/day    # of yrs

Other Tobacco: Pipe Cigar Snuff Chew

Are you interested in quitting? No Yes

Alcohol Use (check box with appropriate answer)

Do you drink alcohol? No Yes
# drinks/week
Is alcohol use a concern for you or others? No Yes

Drug Use:
Do you use any recreational drugs? No Yes
Have you ever used needles? No Yes
Are you currently using drugs? No Yes

Please explain in depth your past and current recreational and pharmaceutical drug use:

Tick box if you are currently taking any anti-depressants? if so, which ones:

MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:

Medication Dose Times per day:

ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS:
Medication Reaction or Side Effect:

PERSONAL MEDICAL HISTORY:

Please select the box if you have you have had any of the following medical problems (with approximate date of illness or diagnosis):

Congenital Heart disease: *specify type: Myocardial Infarction (Heart attack)
Hypertension (High blood pressure)
Diabetes
High cholesterol
Stroke
Thyroid problem *specify type
Coagulation (bleeding/clotting) disorder
Cancer (Malignancy) *specify type
Depression/suicide attempt
Alcoholism
If you have ever had a blood transfusion, please specify date:

Other problems:

When was your last Tetanus shot?

SURGICAL HISTORY (Please list all prior operations and dates):
Operation Date :

FAMILY HISTORY:
Please check a box if any family members have any of the following conditions:

Medical Condition

Alcoholism Genetic disease
Anemia
Anesthesia problem Hay fever (Allergic Rhinitis)
Arthritis Hearing problems
Asthma Heart Attack (Coronary Artery Disease)
Birth Defects High Blood Pressure (Hypertension)
Bleeding problem High cholesterol (Hyperlipidemia)
Cancer, Breast Kidney diseases
Cancer, Colon Lupus (Systemic Lupus Erythematosis)
Cancer, Melanoma Mental retardation
Cancer, skin (except melanoma)
Migraine headaches
Cancer, Ovary Mitral Valve Prolapse
Cancer, Prostate Osteoarthritis
Cancer (not noted) Osteoporosis
Depression Rheumatoid Arthritis
Diabetes, Type 1 (childhood onset)
Stroke
Diabetes, Type 2 (adult onset)
Thyroid disorders
Eczema Tuberculosis
Epilepsy (seizures) other

Psychiatric Disorders: Explain:

EMOTIONS:

1. In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost all interest or pleasure in things that you usually cared about or enjoyed?

No Yes

2. Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?

No Yes

3. Have you felt depressed or sad much of the time in the past year?

No Yes

IMMUNIZATIONS:

Please select a box to indicate your most recent immunizations.
Please include your best estimate of the month and year of each immunization:

Hepatitis A Date:
Hepatitis B Date:
Measles Date:
Mumps Date:
Rubella Date:
Pneumovax (Pneumonia) Date:
Tetanus (Td) Date:
Varicella (chicken pox) shot Date:
Other Date:

REVIEW OF SYSTEMS: Please check a box to indicate any current problems you have on the list below.

Constitutional

Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination

Eyes
Change in vision

Ears/Nose/Throat/Mouth
Difficult hearing/ringing in ears
Problems with teeth/gums
Hay fever/allergies

Cardiovascular
Chest pain/discomfort
Leg pain with exercise
Palpitations

Chest (breast)
Breast lump/discharge

Respiratory
Cough/wheeze
Difficulty breathing

Gastrointestinal
Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea

Genitourinary
Nighttime urination
Leaking urine
Unusual vaginal bleeding
Discharge: penis or vagina
Sexual function problems

Musculo-skeletal
Muscle/joint pain

Skin
Rash or mole change

Neurological
Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination

Psychiatric
Anxiety/stress
Problems with sleep
Depression

Blood/Lymphatic
Unexplained lumps
Easy bruising/bleeding

Other
(please specify)

Comments:

Your E-mail:

*(your email will remain confidential and will not be sold or used for any other publicity)