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KAIROS
Health & Safety Questionaire
First name
*
Last name
*
Nationality
Current Country Of Residence
WhatsApp Number - If You Use Another App: Signal, Telegram, Viber, Please specify
Which retreat are you planning for?
PRIVATE AYAHUASCA RETREAT
MASTER PLANT DIET
Email
*
WhatsApp Number or Phone Number
*
I understand that this questionnaire is used to assess retreat suitability and safety.
YES
NO
Your Age
*
Emergency contact name
*
Emergency contact phone number
Emergency contact relationship to you
*
Have you visited Peru before?
YES
NO
Select The Date You'd LIke To Begin Your Retreat
*
I understand that acceptance into the retreat is not automatic and that Kairos may decline or postpone my participation if the team feels this is not the right or safest time for me.
YES
NO
What is calling you to this experience at this moment in your life?
*
Are you willing to experience discomfort, uncertainty, emotional release, or difficult truths as part of the healing process?
YES
NO
What are the main themes you are hoping to work with? For example: grief, trauma, purpose, depression, anxiety, burnout, addiction, relationship patterns, spiritual connection, identity transition, family patterns, creativity, or emotional healing.
*
What would make this experience most meaningful for you?
*
What do you feel this experience is preparing you to face or understand?
*
Do you feel personally ready to take responsibility for your preparation and integration?
*
Experience with Entheogens, Plant Medicine & Psychedelics
Have you sat with ayahuasca before?
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YES
NO
If yes, how many ceremonies have you participated in?
Have you worked with any other plant medicines or psychedelics? Select all that apply.
*
Ayahuasca
LSD
Psilocybin mushrooms
DMT
5-MeO-DMT / Bufo
San Pedro / Huachuma
Peyote
Iboga / Ibogaine
MDMA / Ecstasy / Molly
Ketamine
Salvia divinorum
Cannabis / Marijuana
Rapé / Hapé
Kambo
Sananga
Mapacho / ceremonial tobacco
PCP
None of the above
I understand that I must answer honestly and update Kairos if anything changes before arrival, including medications, health status, mental-health status, or substance use.
YES
NO
Have you ever had a psychedelic, plant medicine, or spiritual experience that left you feeling unstable, paranoid, dissociated, depressed, anxious, manic, or unable to function afterwards?
YES
NO
I understand that withholding important medical, psychiatric, medication, or substance-use information could put me, the facilitators, and other guests at risk.
YES
NO
I understand that ayahuasca is not a guaranteed cure for any physical, emotional, psychological, relational, or spiritual condition.
YES
NO
I understand that I should not stop, taper, or change prescribed medication without medical supervision.
YES
NO
General Medical History
Do you currently have, or have you ever had, any heart condition?
YES
NO
Do you have, or have you ever had, any of the following? Select all that apply.
*
High blood pressure
Low blood pressure
Irregular heartbeat or arrhythmia
Heart murmur
Heart-valve condition
Heart disease or coronary artery disease
Previous heart attack
Chest pain or angina
Previous stroke or transient ischemic attack
Blood clots, deep-vein thrombosis, or pulmonary embolism
Fainting or unexplained blackouts
Option 12
Circulatory problems
Pacemaker or implanted heart device
None of the above
Other — please explain
Do you have a history of seizures, epilepsy, convulsions, or unexplained blackouts? If yes, please explain.
*
YES
NO
If YES please explain
Do you have diabetes, hypoglycemia, or blood sugar regulation issues?
*
YES
NO
Do you have liver disease, hepatitis, cirrhosis, or elevated liver enzymes?
*
YES
NO
Do you have kidney disease or reduced kidney function?
*
YES
NO
Do you have asthma, sleep apnea, breathing difficulties, or another respiratory condition?
*
YES
NO
Do you have a neurological condition?
*
YES
NO
If YES please explain
Have you had any recent surgery, serious injury, hospitalization, or major illness?
*
YES
NO
If YES please explain
Are you pregnant, trying to become pregnant, or breastfeeding?
*
YES
NO
Do you have any allergies?
*
YES
NO
Do you have any dietary restrictions?
*
YES
NO
Do you have any mobility limitations, chronic pain, physical disability, or injury that may affect your ability to walk on natural jungle terrain?
*
YES
NO
Is there any other medical condition, diagnosis, symptom, or health concern we should know about?
*
YES
NO
If YES please explain
Mental Health History
Have you ever been diagnosed with a mental-health condition?
*
YES
NO
Have you ever experienced or been diagnosed with any of the following? Select all that apply.
Depression
Anxiety disorder or persistent severe anxiety
Panic attacks or panic disorder
Post-traumatic stress disorder (PTSD) or complex PTSD
Bipolar disorder
Mania or hypomania
Psychosis or a psychotic episode
Schizophrenia or schizoaffective disorder
Paranoia, delusions, or hallucinations
Dissociation, depersonalization, or derealization
Obsessive-compulsive disorder (OCD)
Borderline personality disorder
Another personality disorder
Eating disorder, including anorexia, bulimia, or binge-eating disorder
Attention-deficit/hyperactivity disorder (ADHD)
Autism spectrum condition
Substance-induced psychosis, mania, or severe mental-health symptoms
Postpartum depression or postpartum psychosis
Another diagnosed mental-health condition — please specify
I have experienced concerning symptoms but have not received a diagnosis
I am unsure
None of the above
Have you ever been hospitalized for mental-health reasons?
*
YES
NO
If yes include approximate dates/periods of your life and current status
*
YES
NO
Have you ever attempted suicide?
*
YES
NO
Have you ever self-harmed?
*
YES
NO
Are you currently in therapy, psychiatric care, coaching, spiritual counseling, or another support process?
*
YES
NO
Have you recently experienced a major loss, trauma, breakup, shock, or destabilizing life event?
*
YES
NO
Do you currently feel emotionally stable enough to travel internationally and participate in deep ceremony work?
*
YES
NO
Is there anything about your mental health that you feel nervous to disclose but know may be important for us to understand?
*
YES
NO
Medications, Supplements & Herbal Products
Are you currently taking any prescription medication?
*
YES
NO
Is there anything about your mental health that you feel nervous to disclose but know may be important for us to understand?
*
YES
NO
Is there anything about your mental health that you feel nervous to disclose but know may be important for us to understand?
*
YES
NO
Are you currently taking supplements, herbs, or natural products? Select all that apply.
*
Vitamins or multivitamins
Minerals or electrolytes
Herbal or botanical supplements
Adaptogens, such as ashwagandha, rhodiola, or ginseng
Medicinal mushrooms, such as lion’s mane, reishi, or cordyceps
Melatonin or other natural sleep products
5-HTP, tryptophan, St. John’s wort, SAM-e, or other mood-support products
Valerian, kava, passionflower, or other calming products
Amino acids, protein powders, or collagen
Creatine or sports-performance supplements
Pre-workout products, fat burners, or energy supplements
Probiotics, digestive enzymes, or digestive-health products
Hormonal or endocrine products, such as DHEA or thyroid-support supplements
CBD, hemp, or non-prescription cannabis products
OptioTraditional, ceremonial, indigenous, or locally prepared plant remediesn 15
Homeopathic products
None of the above
Other — please specify
Please Specify Here
Do you agree to inform Kairos immediately if you begin, stop, or change any medication or supplement before arrival?
*
YES
NO
Have you ever struggled with addiction, dependency, withdrawal symptoms, or compulsive substance use?
*
YES
NO
Trauma, Regulation & Boundaries
Are there any traumatic experiences, emotional wounds, or life events that may be important for us to know so that we can understand you better before ceremony?
*
YES
NO
When you are overwhelmed, what tends to happen? Select all that apply.
*
I become anxious or panicked
My thoughts race or I cannot think clearly
I become irritable, angry, or defensive
I cry or become highly emotional
I shut down or become emotionally numb
I freeze or find it difficult to move, speak, or respond
I feel disconnected from myself, my body, or my surroundings
I withdraw and want to be alone
I try to leave or escape the situation
I become restless, agitated, or unable to sit still
I become overly agreeable or try to please everyone
I struggle to communicate what I need
I experience physical symptoms such as shaking, nausea, dizziness, sweating, chest tightness, or difficulty breathing
I seek reassurance, physical comfort, or support from others
I use food, alcohol, cannabis, medication, or another substance to cope
OpI experience urges to harm myselftion 16
I experience thoughts of harming someone else
I am generally able to remain present and regulate myself
I am not sure
Other- please explain below
What helps you feel safe when you are overwhelmed?
Are there any boundaries around touch, language, proximity, gender dynamics, authority, music, darkness, or environment that we should know about?
*
YES
NO
If YES please share the details so we are best prepared
Are you comfortable asking for help when you need it?
*
YES
NO
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