Medical Self Assessment Form - Justin Carpenter

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Alternative Medicine Intake Form

Living Healthy Happy Days
Health & Safety Self-Assessment - 2025

Although psychedelic plant based and synthetic medicines remain illegal in most parts of the country, they are safely used both medicinally and recreationally by millions of people in the USA and around the world. We do, however, want to take every precaution to make sure these experiences are beneficial for all parties. Taking this self-assessment is required before participating in any alternative medicine program or event with us.

We ask for this information so we can know in advance about any special medical conditions you may have. For your safety and ours, we will review this form and may contact you to discuss whether the program or event will be a good fit for you considering your current medical history. We will keep the information on this form strictly confidential. Only Justin and/or other organizers who know and understand its confidential nature will see it. The form will be retained along with a liability waiver (if you participate) for a period of one year following your participation in any programs or events and after which they will be permanently deleted. If you choose not to attend for any reason, both the medical intake and liability release forms will be deleted immediately.

Comments & Concerns: These experiences are very safe, but they are not for everyone. Certain medical conditions may indicate a need to re-evaluate and/or postpone participating in a program or event if it represents a significant safety concern. You are highly encouraged to have all your questions and safety concerns addressed before participating. Truthfully answering “no” to every question does not guarantee a positive experience. Please be honest with yourself regarding the self-assessment and your readiness for exploring alternative medicines. We are here to support you through this decision-making process as well as pre and post integration work with any program or event.

MEDICAL INFORMATION SELF-ASSESSMENT

🔶 SECTION 1: Personal Information

Full name

Date of Birth

Gender

Male Female Non Binary Prefer not to say

Phone number

🔶 SECTION 2: Medical History – Please provide brief description for ALL “yes” answers.

Have you had any illnesses in the past year? – Yes/No – If yes, please list all

Have you had any accidents recently? – Yes/No – If yes, please list all

Have you had any surgical operations or been hospitalized recently? – Yes/No – If yes, please list all

Do you have any chronic medical conditions? – Check All That Apply

Asthma Diabetes High Blood Pressure Cardiac Issues (e.g., heart failure, stroke) Bone, Joint, or Muscle Problems Seizures Other - Short Answer

Current Medications: Do you use any antidepressants, SSRI’s, steroids, or antihypertensive medications? – Yes/No – If yes, please list all

Are there any remaining prescription, over-the-counter, or natural medications you are taking? – Yes/No - If yes, please list all

Are you currently pregnant or nursing? – Yes/No

Yes No

Do you have any history of mental health conditions? – Yes/No – If yes, please list all

Have you ever been hospitalized for emotional reasons? – Yes/No – If yes, please list all

Have you ever experienced physically, emotionally, or otherwise - extreme paranoia, anxiety, panic attacks, or other extreme negative experiences while using cannabis or any psychedelic substances? – Yes/No – If yes, please list all

Have you ever had any extremely unusual or disconcerting thoughts, or extreme levels of high energy, or extreme low energy, after the effects of a psychedelic substance should have worn off. – Yes/No – If yes, please list all

Has a health professional ever advised you to cease or otherwise limit consumption of psychedelic substances? – Yes/No – If yes, please describe

Do you have a history of disruptive or violent behavior, either physical or emotional? – Yes/No – If yes, please describe

Do you have a history of traumatic or difficult life events that have not been addressed or are not being supported therapeutically? – Yes/No – If yes, please describe

Do you have any present concerns around suicide or self-harm? – Yes/No – If yes, please describe

Are you currently involved in any legal proceedings? Criminal or civil? (We want to ensure this does not interfere with anything such as probation requirements, etc.) – Yes/No – If yes, please describe

Do you have any other physical or mental limitations or restrictions that might affect your participation? - Yes/No – If yes, please describe

🔶 SECTION 3: Lifestyle and Habits

Do you have any dietary restrictions or preferences? – Yes/No – If yes, please describe

Do you face any major routine stressors in daily life? – Yes/No – If yes, please describe

Do you consume alcohol? – Yes/No

Yes No

If you do consume alcohol, how many drinks per week?

1-3 4-9 10+

🔶 SECTION 4: Goals and Expectations

Have you worked with any alternative medicines in the past? Yes/No - If yes, please list all

What do you hope to achieve by participating in our Alternative Medicine Programs?