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Questionnaire
Eleusinia Visitor Profile Form
First Name
Last Name
Age
Email
Emergency Contact #
Please share a little about your journey and what motivated you to join us at Eleusinia?
SIGNIFICANT MEDICAL HISTORY
Please provide us with your important medical history such as heart problems, asthma, diabetes, high blood pressure, head injuries, major hospitalizations and/or surgeries.
MEDICATION HISTORY
Please provide a list of the medications you're currently taking, along with how often and your current dose. Also, are you dependent on any medically necessary devices (such as a C-PAP, monitors, supplemental oxygen)
HABITUATED SUBSTANCES
Are there any substances you are accustomed to that could lead to withdrawal symptoms while at Eleusinia?
Any allergies to food or medications?
Yes
No
If yes, please list:
Do you experience any challenges with physical movement, such as walking unassisted or standing up from a seated position on the floor?
Yes
No
Do you consume alcohol daily?
Yes
No
Do you agree to receiving medication to alleviate symptoms like nausea, severe discomfort, or distress if our medical team believes it's necessary?
Yes
No
Have you ever suffered from schizophrenia or other forms of psychosis?
Yes
No
Have you experienced psychedelics in the past 5 years? (Please exclude microdosing)
Yes
No
Have you ever been prescribed lithium?
Yes
No
I agree to not consume lithium within 30 days of my retreat date.
*
Participation in any activity at Eleusinia is strictly prohibited if lithium has been consumed within 30 days of the retreat to avoid potential life threatening interactions.
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