Rooted in Iboga

Health Questionnaire

Please answer every question in your own words. It takes about fifteen minutes, and you will hear back within 7 days.

Name

First

Last

Address

Street Address

Address Line 2

City

State

Zip Code

Country

Phone

Date of Birth

Age

Height

Weight

Occupation

Work History

Primary Health Complaints

Your personal health goals you would like to achieve

Brief History of Health Complaints

History of Medications (Include Past and Current)

History of Vitamins, Supplements, Herbs, etc. (Include Past and Current)

History of Surgeries and Hospitalizations

History of Drugs, Caffeine, and Alcohol (Include Past and Current)

Current Sleeping Patterns

History of Exercise Patterns

History of Diet (Include Past and Current)

Frequency of Bowel Movements / Day / Week

Have you ever done an enema? If yes, please explain.

Have you ever done any fasting or water fasting before? If yes, what type of fasting and how many days?

Have you ever done any detox or cleansing protocols? If yes, please specify which detox protocols.

Were you conceived via a natural birth, cesarean section, other, or uncertain?

Are your mother and father living? Please describe your relationships with your parents (Include Past and Current).

How is the health of your parents (alive currently or their health prior to their passing)?

Are you currently married, single, or in a committed relationship?

Do you have children? If yes, what are their ages? Are you still in a relationship with the other parent?

Have you experienced any Amazonian and / or African plant medicines? If yes, which medicines have you experienced?

Are you prepared to make diet and lifestyle changes to improve your health?

Are you open to receiving new education?

How did you learn about our professional retreat services?

Additional Information you would like for us to know.

I consent to Rooted in Iboga collecting the health information in this questionnaire, to evaluate whether a retreat program is safe and appropriate for me. I understand it will be emailed directly to the facilitators and not stored on this website. See our Consumer Health Data Privacy Policy.

Your answers are sent securely and privately to Dr. Nicholas and Daisy only. They are never sold or shared for advertising.