Apply for Treatment Step 1 of 5 - Personal Information 0% Personal InformationName First Last Date of Birth YYYY slash MM slash DD Where do you live? City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Height (specify cm or feet) Weight (specify kg or lbs) Email PhoneDo you have a valid passport? Yes No Do you have any pending legal issue? Yes No Please describe this legal issue: Information Disclosure Experience Ibogaine requires that you provide us with an emergency contact person. This person will only be contacted in case of emergency, and otherwise no information regarding your treatment will be disclosed.Emergency Contact Name First Last Emergency Contact: Relationship to you Emergency Contact Email Emergency Contact PhoneConsent to ContactExperience Ibogaine takes every measure to keep your personal and medical information confidential. In many cases it is desirable for a family member or other loved one to receive updates about the status of your treatment, as well as to be informed about options for continuing care. In order to provide any information, outside of an emergency situation, we require your consent. I consent for Experience Ibogaine to contact a family member of loved one and to discuss aspects of my treatment, my medical records, and my options for continuing care even outside of emergency situations. Is the contact person the same as your emergency contact? Yes No Contact Person Name First Last Contact Person: Relationship to you Contact Person Email Contact Person Phone Substance Use & AddictionUnprescribed SubstancesSubstanceMethod of UseDosageFrequency of Use Including illicit drugs and over the counter substances.Prescribed MedicationMedication NameMethod of UseDosageFrequency of Use Supplements, Herbs, etc.NameMethod of UseDosageFrequency of Use Please describe your history with addiction, past and present:Do you have any prescribed medication that you ARE NOT currently taking? Yes No Prescribed medication you are NOT currently takingMedication namePrescribed forDosage prescribedReason for not taking Please describe any use of alcohol use:Type of alcoholQuantityFrequency Do you consume tobacco? Yes No If yes, what form, how much, and how often? Medical InformationPlease list any food/medicine allergies: Please list all major surgeries you have had:ProcedureApproximate Date What is your last blood pressure reading? What is your resting heart rate? Do you have hypertention or hypotension? Yes No Do you have a history of myocardial infarction or heart disease? Yes No Do you have history of vascular disease including aneurysms? Yes No If yes, please explain: Do you have a history of embolism, problems with blood clotting, or recent trauma to the body including the pelvis or legs? Yes No If yes, please explain: Do you have diabetes? Yes No If yes, are you insulin dependent? Yes No Do you have hypoglycemia? Yes No If yes, please explain: Do you have fainting spells or get dizzy when getting up suddenly? Yes No If yes, please explain: Do you have a history of seizures? Yes No If yes, please explain: Do you have any type of brain damage including traumatic or closed head injury with or without unconsciousness, or seizure? Yes No If yes, please describe: Have you ever had surgery to your gastrointestinal tract or have a history of disease including ulcerative colitis, Crohn's Disease, bleeding or peptic ulcer? Yes No If yes, please explain: Do you have any type of hepatitis including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonia levels, etc.? Yes No If yes, please explain: Do you get nauseous easily? Yes No If yes, please explain: Have you ever coughed up or vomited blood? Yes No If yes, please explain: Do you have insomnia? Yes No If yes, please explain: Are you asthmatic? Yes No If yes, do you use an inhaler? Yes No Do you have sleep apnea? Yes No If yes, do you use a CPAP or BiPAP machine? Yes No What is the condition of your veins? Will you need a central line (if no vein access)? Yes No I don't know Please select all conditions that you have or have had, CURRENTLY OR PREVISOULY. Diabetes Thyroid Problems Cancer Nausea Heartburn Jaundice Painful menstruation Excessive menstruation Loss of mentruation Back problems Muscle spasms Stomach problems Asthma Varicose veins Shortness of breath Bleeding Low blood pressure High blood pressure Joint pain Tuberculosis Stroke Heart problems Swelling Shaking Constipation Urinary problems HIV/AIDS Nerve Damage History of ulcers Diarrhea Renal disease Abdominal pain Respiratory problems Hepatitis A Heart disease Fainting Dizzy spells Obesity If yes to any of the above, please explain: Psychiatric ConditionsDo you consider yourself to be depressed? Yes No If yes, please explain: Have you ever tried to commit suicide? Yes No If yes, please explain: Have you ever been admitted to a psychiatric hospital? Yes No If yes, please provide details:Approximate dateConditions treated Is there anything else you would like to tell us?How did you hear about us?