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We’re here to guide and support you on your healing journey.

Whether you have questions about our retreats, need help with travel logistics, or want to speak with one of our coordinators, we’re happy to connect

Let visitors reach out for more details

Date

Participant Data

Full Name

Age

Gender

Date of Birth

Nationality

Mobile

Occupation

Relationship Status

Emergency Contac number

Hotel

Type of Retreat

I fully understand the value of a honest and complete health history to enable Noi Rao Ancestral Healing Center assist and provide the best care possible.

Could you please share with us what are your goals with the medecine Ayahuasca?

Health History

Vacinated against Covid-19

Your Medical History

Please indicate if you have a history of the following:

Illness Age at Onset

Please kindly let us know if have undertaken a medical evaluation in the last 6 months, if so let.

Let us know the name of your liscensed physcian, and what were the results of your exam were.

Have you noticed if there has been any major changes in your general health in the past 12 months?

Are you now under the evaluation of a Physcian’s care for any particular reason?

Have you ever had any critical illnes, operations or hospitalization? If so please elaborate.

Do you have any cardiovascular disease, including heart attack?

Have you ever had high blood pressure symptoms?

Have you ever had low blood pressure symptoms?

How many cigars do you smoke per day?

Are there any antecedents of alcohol or chemical dependency or emotional issues that may interfere with the care we provide?

Are you currently on a restricted diet? If so please let us know.

Have you ever practice, yoga, meditation, reiki, or any other form self-exploration? if so explain how often.

How did you hear about our retreat center?

Current Medication:

Please list all sort of medication, supplement or vitamins, that you have been taking on a regular basis in the last month, and the date last taken.

Name Frecuency Date

Allergies:

Please list name of specific medication or food that have caused an adverse reaction, specify the reaction.

Medication name:

Food:

Traumas or Abuse:

Have you experienced any trauma, physical or emotional abuse? If you don’t feel comfortable with this method, we can also discuss about this topic privately instead.

Please elaborate:

Family Health Background Is there any member in your family who have had any issues related to high blood pressure or hypertension?

Is there any member in your family who has been diagnosed with diabetes?

Is there any member in your family who has been diagnosed with psychiatric disorders?

Are your father and mother still alive? Yes Could you please share with us how was your relationship in the past?

Do you have siblings?

How many Brothers Sisters? If so, could you please share with us how is your relationship with them in the past and now?

Please let us know if you have ever used any of the following substances.

When was the last time

Cocaine

Mushrooms

Anphetamines

Marihuana

Valium

Heroine

Mezcaline

Crack

Ketamine

Ecstasy

LSD

Alcohol

Nicotine

Only for Women:

Could you please confirm with us if is there the slighlest posibilty that you are pregnant, or if you definitely pregnant?

Clinic Address

Address Will be Here

Opening Hours

Monday - Friday ( 08.00 - 20.00 )

Website

www.domain.com

We’re here to guide and support you on your healing journey.

Let visitors reach out for more details

Clinic Address

Opening Hours

Website

Noi Rao Ancestral Healing Center

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