Health Screening | Iboga Medicine

Your Health & Safety Is Our First Priority!

We carefully screen each individual to ensure the Iboga Retreat is safe, supportive, and appropriate for them. Your health and wellbeing are our highest priority. By understanding your background and any medical considerations, we can provide a secure environment and the right level of guidance throughout the process.

PART 1: CONTACT DETAILS

Full Name

Country

Phone

Date of Birth

Month

Day

Year

Relationship Status

Gender

Pronouns

Occupation

No of hours per week

How did you hear about us?

PART 2: PHYSICAL HEALTH

Mention any past Hospitalizations/Surgeries along with name, date & reason:

Mention any current Medical Diagnosis along with onset date

Mention any past Medical Diagnosis along with onset date

List all supplements you're currently taking including vitamins, herbs, minerals along with dose, frequency, start date & reason.

List all medications you're currently taking including vitamins, herbs, minerals along with dose, frequency, start date & reason.

List your current health concerns in order of importance.

List any food or environmental allergies you experience, along with the reactions to each.

PART 3: MENTAL & EMOTIONAL HEALTH

Have you experienced any trauma?

How many hours do you sleep a night?

Do you wake frequently during the night?

Do you have trouble falling asleep or Staying asleep?

What level of stress are you currently experiencing?

Do you or have you used recreational drugs? If yes please note them*

List your main stressors

What is the approximate date of your last medical exam?

Do you have any pre-existing heart conditions?*

Have you had an EKG (Electrocardiogram) performed? If yes, when, and what were the results?

Are you willing to have an EKG (Electrocardiogram) performed prior to your arrival and share the results with us for our medical team? It is a mandatory requirement for everyone participating in an Iboga ceremony.

An EKG (electrocardiogram) records the electrical activity of your heart and allows our medical team to assess your cardiac health. This simple, non-invasive test helps us identify any potential contraindications—such as QT interval abnormalities—before proceeding with Iboga treatment.

Iboga has specific effects on the heart. One of its known actions is blocking potassium ion channels, which can alter the heart’s rhythm—particularly by prolonging the QT interval. This can lead to irregular, fast, or chaotic heartbeats in sensitive individuals.

For this reason, an EKG is required prior to treatment. It helps determine whether there are any pre-existing cardiac conditions that may increase the risk of adverse effects. Individuals with known cardiovascular disease are not eligible for Iboga treatment, as it is a firm contraindication.

Our approach honors the sacred nature of this medicine and is grounded in a commitment to safety, integrity, and respect for each individual’s healing journey.

Have you ever been diagnosed with any liver conditions or diseases, or have a history of alcoholism?

Have you had a liver panel? If yes, when, and what were the results?

What are the reasons you're seeking Iboga at this time in your life?

Have you had any previous experiences with psychedelics or plant medicines?

How long have you been thinking about doing Iboga?

What are your top three goals with Iboga?*

By signing below, I acknowledge that I have answered all questions truthfully and to the best of my ability. I understand that withholding or providing false information may impact the assessment and recommendations made.

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Your Health & Safety Is Our First Priority!

PART 1: CONTACT DETAILS

PART 2: PHYSICAL HEALTH

PART 3: MENTAL & EMOTIONAL HEALTH

Information

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