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
Name*
First Last
Organization
Website
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I. Daily Usage
How many capsules of IBO+Plus® did you take this week?*
Please enter a value between 0 and 100.
At approximately what time in the morning were the capsules usualy taken?*
: HH
MM
At approximately what time in the afternoon were the capsules usually taken?*
: HH
MM
How many times were capsules taken during the day?*
How many capsules were taken at each administration?*
In addition to IBO+Plus®, did you take vitamins and/or or energy supplements this week?*
- Yes
- No
If you answered "Yes", what please list all vitamins and/or supplements taken this week.
Do you take vitamins regularly?*
- Yes
- No
Do you take iron pills regularly?*
- Yes
- No
Do you regularly take energy supplements?*
- Yes
- No
II. Appetite
After taking IBO+Plus®, do you find that your appetite suppressed?*
- Yes
- No
After taking IBO+Plus®, do you find that your appetite increased?*
- Yes
- No
After taking IBO+Plus®, do you experience the need to ingest more water or other liquids?*
- Yes
- No
After taking IBO+Plus®, do experience greater hunger or thirst than usual?*
- Yes
- No
III. Alcohol & Tobacco Use
Do you usually consume two or more alcoholic drinks per day?*
- Yes
- No
After taking IBO+Plus®, do you find that your consumption of alcohol beverages has increased?*
- Yes
- No
After taking IBO+Plus®, do you find that your consumption of alcoholic beverages has decreased?*
- Yes
- No
Do you normally smoke more than 20 cigarettes per day?*
- Yes
- No
After taking IBO+Plus®, do experience an increased craving for tobacco?*
- Yes
- No
After taking IBO+Plus®, do you smoke fewer cigarettes than usual?*
- Yes
- No
After taking IBO+Plus®, has your use of tobacco remained the same?*
- Yes
- No
IV. Sleep Habits
Do you usually have great difficulty in falling asleep?*
- Yes
- No
Do you regularly take a sleep aid at night to fall asleep?*
- Yes
- No
Do you find it impossible to take a regular rest period during the day?*
- Yes
- No
Do you drink more than six cups of coffee or tea per day?*
- Yes
- No
V. Additional Subjective Effects
After taking IBO+Plus®, do you sweat or tremble?*
- Yes
- No
After taking IBO+Plus®, do you become nervous or jittery?*
- Yes
- No
After taking IBO+Plus®, does your thinking become confused?*
- Yes
- No
After taking IBO+Plus®, do you become scared to be alone?*
- Yes
- No
After taking IBO+Plus®, is it more difficult for you to make up your mind?*
- Yes
- No
After taking IBO+Plus®, do you feel exhaustion or fatigue?*
- Yes
- No
After taking IBO+Plus®, do you have unusual thoughts racing through*
- Yes
- No
After taking IBO+Plus®, do you experience increased energy levels?*
- Yes
- No
After taking IBO+Plus®, do you experience increased alertness?*
- Yes
- No
After taking IBO+Plus®, does your mind wander?*
- Yes
- No
After taking IBO+Plus®, do you find it easier to concentrate and focus your attention?*
- Yes
- No
After taking IBO+Plus®, do you feel people unknown are watching you?*
- Yes
- No
After taking IBO+Plus®, do you feel more friendly towards people?*
- Yes
- No
After taking IBO+Plus®, do you feel more relaxed?*
- Yes
- No
After taking IBO+Plus®, do you become depressed?*
- Yes
- No
After taking IBO+Plus®, do you experience anxiety?*
- Yes
- No
After taking IBO+Plus®, do you feel relaxed?*
- Yes
- No
After taking IBO+Plus®, do you feel comfortable?*
- Yes
- No
After taking IBO+Plus®, do you feel at ease?*
- Yes
- No
After taking IBO+Plus®, do you feel more self-confidence?*
- Yes
- No
After taking IBO+Plus®, do you feel more focused?*
- Yes
- No
VI. Eyes
After taking IBO+Plus®, do your eyes continually blink or water?*
- Yes
- No
After taking IBO+Plus®, do your eyes become red or inflamed?*
- Yes
- No
After taking IBO+Plus®, do you experience double vision, visualizations, or hallucinations?*
- Yes
- No
After taking IBO+Plus®, do you experience a loss of vision or black out?*
- Yes
- No
After taking IBO+Plus®, do you experience eye pain?*
- Yes
- No
VII. Ears
After taking IBO+Plus®, do you notice ringing in your ears?*
- Yes
- No
After taking IBO+Plus®, do you experience any changes in your hearing?*
- Yes
- No
VIII. Nose & Throat
After taking IBO+Plus®, do you have to clear your throat more frequently than usual?*
- Yes
- No
After taking IBO+Plus®, do you feel a lump in your throat?*
- Yes
- No
After taking IBO+Plus®, does your nose become stuffed up?*
- Yes
- No
After taking IBO+Plus®, does your nose run constantly?*
- Yes
- No
After taking IBO+Plus®, does your nose bleed?*
- Yes
- No
After taking IBO+Plus®, do you experience soaking sweats?*
- Yes
- No
IX. Heart & Lungs
After taking IBO+Plus®, do you experience shortness of breath?*
- Yes
- No
After taking IBO+Plus®, do you experience pain in the heart or chest?*
- Yes
- No
After taking IBO+Plus®, does your heart race like mad?*
- Yes
- No
After taking IBO+Plus®, do you find it hard to breathe?*
- Yes
- No
X. Teeth & Gums
After taking IBO+Plus®, do you gums bleed?*
- Yes
- No
After taking IBO+Plus®, do you have difficulty or pain in swallowing?*
- Yes
- No
After taking IBO+Plus®, do you experience mouth sores or sores on the*
- Yes
- No
XI. Joints
After taking IBO+Plus®, do your joints become painful or swollen?*
- Yes
- No
After taking IBO+Plus®, do your muscles or joints feel stiff?*
- Yes
- No
After taking IBO+Plus®, do you experience pain in your arms and/or legs?*
- Yes
- No
XII. Skin
After taking IBO+Plus®, do you experience any new skin conditions?*
- Yes
- No
After taking IBO+Plus®, do you have any skin rashes?*
- Yes
- No
After taking IBO+Plus®, does your skin become sensitive or tender?*
- Yes
- No
After taking IBO+Plus®, does your face become flushed?*
- Yes
- No
After taking IBO+Plus®, do you sweat a great deal?*
- Yes
- No
After taking IBO+Plus®, do you experience severe itching?*
- Yes
- No
XIII. Head
After taking IBO+Plus®, do you experience frequent headaches?*
- Yes
- No
After taking IBO+Plus®, do you experience pressure or pain in the head?*
- Yes
- No
After taking IBO+Plus®, do you experience severe dizzy spells?*
- Yes
- No
After taking IBO+Plus®, do you experience hot or cold spells?*
- Yes
- No
After taking IBO+Plus®, do you feel faint or have fainted?*
- Yes
- No
After taking IBO+Plus®, do you experience a numbness or tingling in any part of the body?*
- Yes
- No
After taking IBO+Plus®, do you experience twitching of the face, head, or shoulders?*
- Yes
- No
XIV. Bladder & Sexual Function
After taking IBO+Plus®, do you have trouble urinating?*
- Yes
- No
After taking IBO+Plus®, do you urinate frequently?*
- Yes
- No
After taking IBO+Plus®, do you experience pain or burning when urinating?*
- Yes
- No
After taking IBO+Plus®, do you lose control of your bladder?*
- Yes
- No
After taking IBO+Plus®, do you have trouble getting sexually aroused or achieving orgasm?*
- Yes
- No
After taking IBO+Plus®, do you experience any change in your sexual activity?*
- Yes
- No
After taking IBO+Plus® as a participant in a clinical study, would purchase this Natural Health Product if it was available at a retail outlet?*
- Yes
- No
Additional Comments

Personal Information

I. Daily Usage

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

2016 Conference

ACLS for Ibogaine Therapy

Clinical Guidelines

About Us

Stay Connected

Recently From Our Blog

Signup for our Newsletter