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Health questionnaire

Your health questionnaire

This confidential questionnaire helps us make sure ayahuasca is safe and right for you. Your answers go straight to our team — no one else.

Please complete this questionnaire thoroughly. All the information you provide is strictly confidential and will not be shared outside of our organization.

Guest information
Sex
Date of birth
Health history Check all that apply:
Medications & substances
Are you currently taking, or have you taken in the last 3 months, any SSRIs, MAOIs, or antipsychotic medications?
Have you ever used any recreational drugs, including psychedelics?
Medical history
Are you currently under a physician's care?
Have you had any serious illness, surgery, or hospitalization?
Do you have high or low blood pressure?
Are you pregnant or breastfeeding?
Digestion
Diet & lifestyle
Are you on a restricted diet?
Mental & emotional health
Have you ever received a psychiatric or psychological diagnosis or treatment?
Are you currently in therapy or a support group?
Do you practice meditation, yoga, or other mindfulness practices?
Trauma & abuse
Have you experienced any trauma or abuse (physical or emotional)?

You may choose to discuss this in a private conversation with Ayaselva staff instead — you do not have to write it here.

Family & relationships
Are your parents still alive?
Do you have siblings?
Your motivation
Consent to process your health data

This form includes data about your health — a special category of personal data. We use it only to assess whether a retreat is safe and appropriate for you and to prepare your personal care. It is sent securely to Ayaselva, is never shared with any third party, and is kept only for as long as needed for your retreat, then deleted.

Read our Privacy Policy →

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