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Medical History
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Past Medical History
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Past Medical History Comments
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Past Surgical History
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Past Surgical History Comments
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Date of last PE
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Comments
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PCP
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PCP Contact Information
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Social History
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Marital Status
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Comments
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Living Arrangements
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Comments
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Occupation
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Comments
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Patient's diet
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Comments
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The primary condition you are seeking treatment?
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How long have you been dealing this condition?
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Do you have any other conditions/diagnosis?
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Have you been diagnosed schizophrenic or bipolar
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Are you currently taking benzodiazepines?
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Are you currently taking Lamotrigine (Lamictal)?
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Are you currently taking any MAOIs?
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Undergoing treatment(s) other than pres med
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Have you ever had anesthesia before?
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If yes, did it have any adverse effects?
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Have you tried treatments other than >>
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prescription drugs in the past? (Ex:ECT,TMS,etc)
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Use drugs prescription or other, recreationally?
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If so, which drugs, how often, and last use?
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Pregnant, breastfeeding or planning?
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Do you drink alcohol? How much? Last use?
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Do you smoke tobacco? How much? Last use?
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Have you had brain surgery, tumors, or blood >>>
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vessel malformations in the past?
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Ever been hospitalized in a psychiatric unit?
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If so, when, why, where, and for how long?
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How did you hear about us?
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Friend/Family Member (List Who)
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Provider Referral (List Who)
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Other (List)
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May we leave voicemails pertaining to treatment
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May we send emails pertaining to your treatment
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Mental Health Practitioner #1
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Full Name
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Specialty
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Phone Number
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How long has he/she been treating you?
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When was the last time you saw him/her?
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Mental Health Practitioner #2
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Full Name
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Specialty
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Phone Number
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How long has he/she been treating you?
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When was the last time you saw him/her?
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Pain Specialist #1
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Full Name
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Specialty
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Phone Number
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How long has he/she been treating you?
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When was the last time you saw him/her?
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Pain Specialist #2
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Full Name
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Specialty
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Phone Number
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How long has he/she been treating you?
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When was the last time you saw him/her?
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Other Treating Physician
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Full Name
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Specialty
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Phone Number
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How long has he/she been treating you?
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When was the last time you saw him/her?
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Are you or have you recently been suicidal? >>>>
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If yes, please distinguish to what degree?
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Other
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Have you ever had a Ketamine Infusion before?
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If so, please list when, where, with which doc
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List number of infusions and describe in detail?
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What are you expecting to gain from treatment?
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If you got the best possible results >>>>
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from our treatment, what would that look like?
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