OMS Ceremony & Medical Questionnaire

OMS Ceremony Questionnaire

Name *

City and State of Residency *

Date of Birth *

Blood Type (if known)

A+

A-

B+

B-

AB+

AB-

O+

O-

Religious Afilliation

Christianity

Islam

Buddhism

Judaism

Kabbalism

Scientology

Atheist

Universal

Other

If you selected "other" for your religious affiliation, tell us about it here.

Why do you want become an OMS member?

Why do you want to attend an OMS ceremony? *

Have you ever utilized Sacraments? If so, what have you utilized? *

If you have utilized Sacraments, what effects do they have on you? *

Are there effects, or results that you would like attain from Sacraments, but have been unable to do so? If so, provide details here.

Have you ever utilized Sacraments with a group of people in a ceremonial context? *

Do you have allergies to foods or medications? If so, list them here. *

Do you have any medical conditions? If so, list them here. *

Do you have any mental health conditions? If so, list them here. *

Have you been hospitalized for a physical or mental illness in the past 24 months? If so, provide details here. *

Are you currently suicidal, homicidal, or experiencing visual or auditory hallucinations? If so, provide details here. *

Are you currently on medication? If so, list the medications and reason(s) why they were prescribed here. *

This is very important, some sacraments such as Syrian Rue or Banisteriopsis Caapi cannot be combined with certain medications.

If there is anything else you would like us to know, provide details here.

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