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Master Plants & Presence
Health & Medical Pre-Screening
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Health & Medical Pre-Screening Form
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Which dieta are you participating in?
Bobinsana
Chuchuhuasi
Blue Lotus
All of the Above
Have you previously participated in a Master Plants & Presence dieta?
No, this is my first dieta
Yes
If yes, which plant(s) have you previously dieted with?
Blue Lotus
Bobinsana
Chuchuhuasi
Other
Answer
No
Yes
I'm Not Sure
Do you currently have, or have you previously had, any significant medical conditions?
No
Yes
Please check any that apply to you, currently or in the past:
Heart or cardiovascular condition
High or low blood pressure
Blood clot, DVT, pulmonary embolism, or bleeding/clotting disorder
Diabetes or blood-sugar condition
Kidney condition or impaired kidney function
Liver condition
Ulcerative colitis, Crohn’s disease, ulcers, or another significant gastrointestinal condition
Autoimmune condition
Neurological condition or seizures
Cancer or current/recent cancer treatment
Significant allergy or sensitivity
Other significant medical condition
None of the Above
Medications - Are you currently taking any prescription or over-the-counter medications?
Yes
No
Have you taken a blood thinner/anticoagulant within the past several years?
Yes
No
Are you currently experiencing any of the following?
Active illness or infection
Flare of a chronic or autoimmune condition
Significant digestive symptoms
Unexplained bleeding
Significant change in your health
Recent hospitalization
Upcoming surgery, medical procedure, or significant medical treatment
None of the above
Are you currently pregnant, breastfeeding, trying to become pregnant, or is there a possibility you may be pregnant?
No
Yes
Unsure
Answer
Yes
No
Answer
Yes
No
Have you worked with this plant or these plants before, either through Master Plants & Presence or elsewhere?
Yes
No
By checking this box, I confirm that the information I have provided is complete and accurate to the best of my knowledge. I understand that I should not stop, reduce, or otherwise change a prescribed medication in order to participate in a dieta unless instructed to do so by my prescribing healthcare provider, and I agree to the acknowledgment above.
Submit
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