03 / Medical history Important for safety assessment Draft questions, awaiting clinical sign-off. These follow ordinary plant-medicine harm-reduction practice. What AscentFive does with the answers — which of them rule someone out, who is qualified to read them, and who is responsible in an emergency — has not been decided, and is not described anywhere on this page.
Do any of these apply to you, now or in the past? Tick everything that applies. Leave them all unticked if none do. Cardiovascular or heart condition High or low blood pressure A stroke, aneurysm or other neurological event Epilepsy or seizures A liver or kidney condition Diabetes Asthma or another respiratory condition Pregnancy, or currently breastfeeding Surgery or a hospital admission in the last twelve months
And any of these? A close blood relative matters for the first two, because the risk runs in families. Psychosis or schizophrenia, in you or in a parent, sibling or child Bipolar disorder, in you or in a parent, sibling or child Another mental health diagnosis, now or in the past Thoughts of suicide or self-harm, now or in the past Currently seeing a psychiatrist, psychologist or therapist A previous psychedelic experience that was overwhelming or frightening
Please describe anything you ticked optional When it started, how it is now, and anything a doctor has told you about it.
Do you take any of these? These are asked about by name because they interact with 5-MeO-DMT, and people do not always think of them as relevant. If you are unsure what class a medicine belongs to, leave these unticked and write its name below. An MAOI An SSRI or SNRI antidepressant Lithium Tramadol An antipsychotic A stimulant, including ADHD medication St John’s wort or 5-HTP None of these
Current medications (list all) Include prescription, over-the-counter, and supplements, with doses. Write “none” if you take nothing.
Alcohol or other substances optional Roughly what and how often. This is asked for your safety, not for judgement.
Emergency contact Someone we could reach on the day. Please make sure they know you have given their details. 05 / Safety acknowledgment Draft wording, not legally reviewed. The statement below makes a legal claim about who carries the risk, and it has not been checked against Dutch law or confirmed by AscentFive. The privacy notice, the lawful basis for holding these answers, the retention period and the deletion route are still missing entirely. The form is closed to submissions until all of that exists.
I take full responsibility for my wellbeing and decisions