Health Questionnaire Safety Assessment

Why do a safety assessment?

Psilocybin, and psychedelics generally, are considered very safe. There is an extremely low chance of lethal overdose or addiction. That said, they aren’t for everyone. There are some clear exclusion criteria for this - things like medications and family or personal mental health history. For that reason, we ask everyone to fill out a medical safety assessment before a psychedelic journey. This ensures that you as a participant have the best possible experience and best mitigate the risks.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Are you Pregnant or Nursing?

Yes

No

Are you on any on SSRIS?

Yes

No

Are you on any on Benzodiazepines?

Yes

No

Are you on any Opiates?

Yes

No

Are you on any Zofran?

Yes

No

Are you currently having any thoughts of causing harm, or wanting to cause harm, to yourself or others?

Yes

No

Have you had a diagnosis of psychosis (hallucinations, delusions, disordered thinking or speaking), bipolar disorder, or schizophrenia?

Yes

No

Have you taken the drug Lithium in the past 30 days?

Yes

No

Have you ever been diagnosed or suspect you have any of the following medical conditions?

Do you currently use any prescription or over-the-counter medicine? If so, please list them.

Have you ever had a negative reaction or event during a psychedelic journey?

Yes

No

Have you had an allergic reaction to any fungus or mushrooms (psilocybin-containing or otherwise)?

Yes

No

I certify, warrant and represent that the information provided above is a complete and accurate statement of the physical and psychological conditions that may affect my use of psilocybin. Mush Love does not provide any medical or mental health services, and cannot medically clear you to engage in the voluntary use of psilocybin. Mush Love assumes no responsibility for any claims or damages caused by your failure to disclose or misrepresentation of medical or mental health information.

I undertake full responsibility to notify Mush Love should there be any changes in my health status.

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Health Questionnaire Safety Assessment

Why do a safety assessment?