IBO+Plus Questionnaire

We request that you fill out the following questionnaire at the end of each week, for four consecutive weeks after beginning the IBO+Plus® regiment. Thank you for taking the time to share your experience and help to make this medicine more available.

  • Personal Information

  • I. Daily Usage

  • Please enter a value between 0 and 100.
  • :
  • :
  • II. Appetite

  • III. Alcohol & Tobacco Use

  • IV. Sleep Habits

  • V. Additional Subjective Effects

  • VI. Eyes

  • VII. Ears

  • VIII. Nose & Throat

  • IX. Heart & Lungs

  • X. Teeth & Gums

  • XI. Joints

  • XII. Skin

  • XIII. Head

  • XIV. Bladder & Sexual Function

©2012-2018 Global Ibogaine Therapy Alliance - Privacy Policy - Contact Us

or

Log in with your credentials

or    

Forgot your details?

or

Create Account