Magalies Wellness Centre
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Home
Who We Are
About Ibogaine
Our Programmes
Application Form
Gallery
Media
Testimonials
Resources
Contact Us
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Personal Information
Name
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First
Last
Address
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City
State
Zip Code
Country
Country
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Citizenship
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Phone Number
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Cell Number
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Email
*
ID/Passport Number
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Weight
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Height
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Date of Birth
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Marital Status
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Single
Married
Divorced
Widowed
Domestic Partners
Dependants
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0
1
2
3
4
5
+5
Primary Physician Name
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Physician Phone Number
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Medical Aid
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No
Yes
Medical Aid Information
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Emergency Contact Details
Name
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First
Last
Relationship
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Cell Number
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Drug History
What substance(s) are you seeking detoxification from? Please list amount or dosage, what form(s) you take it in and how often you use:
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Are any of these substances prescribed to you by a doctor or therapist? If so please provide details:
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Have you ever been abstinent from the substance/s you are seeking to detoxify from? If so, how long did this period of time last?
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Do you drink alcohol? (If yes, please provide details below when asked about other substances that you use)
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No
Yes
Please describe your usual withdrawal symptoms (if any):
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If so, what did you find helpful in maintaining abstinence?
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Do you smoke tobacco?
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No
Yes
Do you use Cannabis? (Please provide details about your cannabis use below when asked about other substances. Please also provide details about what forms you use it in, such as whether you smoke it, eat it etc... Please be specific.)
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No
Yes
Are you using any other substances? If so, please list amount or dosage, what form you take it in and how often (Please include all other substances including alcohol or any other legal or illegal substances):
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Please provide a detailed chronological history of your substance use (Please list dates and details of your use. ie: 1990 - 1994 injected heroin twice a day and smoked crack 3 -5 times on weekends):
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Please list other detox or treatment programs you have participated in, and tell us why they did or didn't work for you:
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Have you participated in Narcotics Anonymous or Alcoholics Anonymous?
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No
Yes
Have you ever tried ibogaine therapy before?
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No
Yes
If so, please provide an account of your ibogaine therapy and the outcome:
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Do you participate in any counseling or other forms of therapy or support groups? If so, please provide details:
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Do you have a sex or porn addiction?
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No
Yes
Do you have a video game addiction?
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No
Yes
Do you have an eating disorder?
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No
Yes
Please describe your plans for aftercare. List any aftercare options which appeal to you:
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Medical History
Check Where Applicable
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Abdominal Pain
Alcoholic Cardiomyopathy
Arrhythmia
Blackouts
Back Problems
Cancer
Chest Pain
Chronic Diarrhea
Chronic Inflammation
Delirium Tremens
Dizzy Spells
Epilepsy
Gynecological Problems
Heart Arrhythmia
Heart Murmur
Hepatitis C
History of Heart Attack
Infections
Irritable Bowel Syndrome
Kidney Stones
Magnesium Deficiency
Myocardial Infarction
Obesity
Palsy
Prolonged QT Syndrome
Severe Headaches
Shortness of Breath
Stomach Problems
Tremors
Tuberculosis
Urinary Infection
Venous Insufficiency
Choose Any
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Abscess
Angina Pectoris
Asthma
Bradycardia
Bleeding
Celiac Disease
Chrohns Disease
Chronic Fainting
Cluster Headaches
Diabetes Type 1
Emphysema
Eye Pain
Headaches
Heart Disease
Hepatitis A
Hypertension Untreated
HIV
Inflammatory Bowel Disease
Joint Pain
Liver Disease
Migraines
Nerve Damage
Painful or Excessive Menstruation
Peptic Ulcer
Seizures
Sexually Transmitted Disease
Skin Infection
Stroke
Thyroid Low
Tumor
Varicose Veins
Venous Thrombosis
Choose Any
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AIDS
Ankle Feet or Leg Swelling
Arteriosclerosis
Bronchitis
Blood Clots
Cerebellar Dysfunction
Chronic Abdominal Pain
Chronic Fatigue
Coronary Artery Disease
Diabetes Type 2
Endometriosis
Faintness
Heartburn
Heart Irregularities
Hepatitis B
High Cholesterol
Hypotension Untreated
Irregular Pulse
Kidney Disease
Lung or Respiratory Disease
Muscle Pain
Numbness
Palpitations
Pericarditis
Severe Cough
Shaking
Staph Infection
Tachycardia
Thyroid High
Ulcer
Vascular Disease
Other
If you answered yes to any of the preceding questions, please provide details here:
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Do you or your family have any history of cardiac abnormalities, heart attack or stroke? If so, please provide details.
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Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If so, Please provide details.
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Please list any medications you are presently taking or have taken in the past 6 months. Please list amount or dosage and how often (Please include all medications whether they are prescribed to you or not):
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Are you taking any steroids or hormones such as HGH (Human Growth Hormone)? If so, please list amount or doseage and how often:
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Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking. Please list amount or dosage and how often.
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Please list any depo injections or other injections that you have been given recently or regularly:
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Do you have a chronic pain issue? If so, please describe (Please tell us about the source of your pain and what you do to manage it):
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If you have chronic pain please describe the severity by choosing on a scale from 1 to 10 (1 represents hardly any pain at all, while 10 represents the worst imaginable pain).
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1
2
3
4
5
6
7
8
9
10
Please list all prior surgeries or operations including dates:
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Do you have any allergies to foods, medications, herbs or drugs? If so, please describe:
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Have you ever been diagnosed with or do you have any psychiatric conditions? Please describe eg. Borderline Personality Disorder, Bi Polar Disorder, Major Depression, Uncontrollable Anxiety, Obsessive-Compulsive Disorder, Schizophrenia, Panic Disorder.
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Are you currently undergoing care for a psychiatric condition? Please describe (If yes, please also list any medications you are taking for this):
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Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)?
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No
Yes
Have you ever had a Holter monitor heart test (A heart test where you wear a monitor for 24 hours)?
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No
Yes
Metabolism
Would you consider your metabolism of substances/drugs to be normal, high or low?
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Normal
Low
High
When taking substances do you find you usually need more or less than most people do for an effect from a regular dose?
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General Doses Work
Generally Higher
Generally Lower
Have you ever taken a substance/drug that had little or no effect? If so please describe.
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Have you ever had an adverse or allergic reaction to any medications or drugs? If so please describe what it was and the dosage/s taken.
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Have you ever had a CYP2D6 metabolism test?
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No
Yes
If so, please tell us what your CYP2D6 metabolism phenotype is:
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Poor Metabolizer
Intermediate Metabolizer
Extensive Metabolizer
Ultrarapid Metabolizer
If you are HIV Positive, Are you using Anti-Viral Medication ?
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No
Yes
Tell Us About Yourself
Please describe any goals you have, what kinds of things motivate you in your recovery?
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Please describe what you do in your career, work or study:
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Please describe what your social support network is like (such as family, friends, co-workers):
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Do you have any spiritual practices or beliefs?
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Please describe your living environment, do you consider it to be healthy or unhealthy?
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Please describe your eating habits and your relationship to nutrition:
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Do you feel like you could use some counseling in learning more about nutrition?
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Yes
No
Are you a vegetarian?
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No
Yes
Have you ever taken a psychedelic or entheogen? If so, please describe:
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If so, have you had any negative experiences or reactions to these? Please describe:
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COVID-19 Screening Questionnaire
Do you currently have a cough?
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Yes
No
Do you experience shortness of breath?
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Yes
No
Do you experience chest pains?
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Yes
No
Do you currently have a sore throat?
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Yes
No
Have you recently loss your sense of smell?
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Yes
No
Have you recently noticed an alteration in your sense of taste?
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Yes
No
Are you experiencing a high fever?
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Yes
No
Are you experiencing any muscle pain?
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Yes
No
Have you been experiencing any diarrhoea lately?
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Yes
No
Have you been in close contact with anyone who tested positive, or is suspected to have COVID-19? If yes, please provide details.
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Yes
No
Comment
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Have you been in contact with anyone where confirmed cases of COVID-19 have been established at their institution/place of work/place of worship? If yes, please provide the details.
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Yes
No
Comment
*
Almost Done!
Please tell us what your intentions and/or expectations are for your ibogaine therapy:
*
Is there anything else you would like to tell us about yourself?
*
Submit
Home
Who We Are
About Ibogaine
Our Programmes
Application Form
Gallery
Media
Testimonials
Resources
Contact Us