TRAVESÍA

Medical Form

Health screening.

For your safety and well-being, please answer the following questions honestly. All information is confidential.

Psychiatric History

1. Have you ever been diagnosed with schizophrenia, psychosis, or schizoaffective disorder? *

2. Do you have a history of bipolar disorder type I with manic or psychotic episodes? *

3. Have you experienced psychotic episodes or hallucinations without substance use? *

4. Do you suffer from severe anxiety disorder or uncontrolled PTSD? *

5. Have you been hospitalized for a severe mental disorder within the last 12 months? *

6. Do you have a family history of schizophrenia or other psychotic disorders? *

Note: Psilocybin may induce or worsen psychotic symptoms in individuals with a history of these conditions.

Medical Conditions

7. Do you have high blood pressure that is not well controlled with medication? *

8. Have you had a heart attack, coronary disease, or heart failure? *

9. Have you been diagnosed with cardiac arrhythmias or do you have a pacemaker? *

10. Do you have prosthetic heart valves or a history of recent thrombosis? *

11. Do you suffer from epilepsy or have had seizures in the past? *

12. Do you have severe liver disease or cirrhosis? *

13. Are you pregnant or breastfeeding? *

Current Medication

14. Are you taking antipsychotics (e.g., risperidone, olanzapine, clozapine)? *

15. Are you taking SSRIs (e.g., fluoxetine, sertraline, paroxetine)? *

16. Are you taking Monoamine Oxidase Inhibitors (MAOIs)? *

17. Are you being treated with antihypertensives (beta blockers, ACE inhibitors, ARBs)? *

18. Do you use anticoagulants such as warfarin, heparin, or high-dose aspirin? *

19. Do you take heart medications such as digoxin? *

Substance Use History

20. Do you have a history of substance abuse? *

21. Have you had severe dependence on alcohol, opioids, or benzodiazepines in the last year? *

22. Have you experienced serious adverse effects from psychedelics in the past? *

General Considerations

23. Are you currently participating in another clinical trial or experimental treatment? *

24. Have you recently undergone surgery or have an unstable medical condition? *

25. Do you have extreme fear or anxiety about losing control under the influence of any substance? *

Medications

Check any medications you currently take:

Monoamine Oxidase Inhibitors (MAOIs)

Antipsychotics

Central Nervous System (CNS) Stimulants

Triptans (Migraine Treatment)

Anticoagulants & Cardiovascular Medications