EVOLUTION HOUSE ROOTS TO RISE AYAHUASCA RETREAT

CONFIDENTIAL HEALTH QUESTIONNAIRE + LIABILITY WAIVER & DISCLAIMER

(Required for participation in plant medicine ceremonies and physical activities)

First name

Last name

Phone

Address

Birthday

Year

Month

Day

Emergency Contact Name and Phone Number:

Preferred pronouns:

PART 2: PLANT MEDICINE CONTRAINDICATIONS CHECKLIST

Ayahuasca, Kambo, Bufo (5-MeO-DMT), and Cacao are powerful medicines with potential risks.

Please answer truthfully. These answers will help ensure your safety and eligibility.

Mental Health History

Do you have a current or past diagnosis of (check all that apply):

Schizophrenia

Bipolar Disorder

Borderline Personality Disorder

Major Depression

PTSD / C-PTSD

Severe Anxiety or Panic Disorder

History of Psychosis / Hallucinations

Suicide attempts or ideation

Please note: Ayahuasca, Bufo, and Kambo are not recommended for individuals with a history of psychosis, schizophrenia, or bipolar disorder.

Medication Use (past 30 days)

Are you currently taking or recently stopped any of the following? (check all that apply)

SSRI / Antidepressants (e.g., Prozac, Zoloft)

MAOIs / Antipsychotics / Lithium

Benzodiazepines (e.g., Xanax, Ativan)

Stimulants (e.g., Ritalin, Adderall)

Sleep medications or sedatives

Painkillers or opioids

Hormonal contraceptives

Any recreational drugs

Recent anesthesia (surgery within 4 weeks)

If yes to any, please list medication names, dosages, and dates stopped (if applicable):

Certain medications, especially SSRIs and MAOIs, are dangerous when combined with Ayahuasca and Bufo. A proper taper and medical consultation is required before participating.

Physical Health History

Do you currently have, or have you ever had (check all that apply):

Heart disease or arrhythmia

High or low blood pressure

Stroke or aneurysm

Epilepsy or seizures

Diabetes or blood sugar imbalance

Thyroid disorders

Asthma or lung issues

Liver or kidney disease

Glaucoma

Pregnancy or breastfeeding

Fainting or blackouts

Plant Medicine Experience

Have you previously experienced (check all that apply):

Ayahuasca

Kambo

Bufo/5-MeO-DMT?

Ceremonial Cacao

If yes to any, please describe each experience and how many times:

Contraindications and Sensitivities

Do you have any known allergies or sensitivities to frog venom (Kambo), Theobromine (Cacao), or DMT (Bufo)?

Yes

Do you follow a special diet (e.g., vegan, low sodium, gluten-free)?

Yes

If yes, please specify:

Do you have a history of sexual or physical trauma?

Yes

If yes, are you currently in therapy or have support in place?

PART 3: INFORMED CONSENT + WAIVER OF LIABILITY

Acknowledgments

By signing this form, I understand and agree to the following:

1. I am participating voluntarily in the Evolution House Roots to Rise Ayahuasca Retreat, which includes:

Ayahuasca, Kambo, Bufo, Cacao ceremonies

Breathwork, sound healing, meditation, yoga

Cold plunge, swimming, nature hikes, quad riding, snorkeling

Emotional and spiritual self-exploration

2. I have disclosed all relevant health and medical information.

I understand withholding information may result in physical or psychological harm.

3. I accept full responsibility for the risks involved in participating in these activities and understand that facilitators are not licensed medical or psychiatric professionals.

4. I will not hold Evolution House, facilitators, staff, or partners liable for any injury, loss, or condition that arises from my participation.

PART 4: MEDIA RELEASE (Optional)

I allow Evolution House to take and use photos/videos of me during the retreat for promotional purposes.

Yes

PART 5: FINAL DECLARATION

I confirm the information I have provided is accurate and complete.

I understand the risks, benefits, and nature of the retreat, and I am participating of my own free will.

Date picker

Signature

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EVOLUTION HOUSE ROOTS TO RISE AYAHUASCA RETREAT

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