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1. Please fill out this brief measure of disability and impairment.
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Sheehan Disability Scale (SDS)
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1. In the LAST WEEK, my symptoms have disrupted my work / school work? (scale 0-10)
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In the LAST WEEK, I have not worked / studied at all for reasons UNRELATED to my symptoms.
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2. In the LAST WEEK, my symptoms have disrupted my social life / leisure activities? (scale 0-10)
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3. In the LAST WEEK, my symptoms have disrupted my family life / home responsibilities? (scale 0-10)
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4. In the last 7 days, my symptoms made me miss work / left me unable to carry out my responsibilities?
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5. In the last 7 days, I felt so impaired by my symptoms that when working my productivity was reduced?
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2. Please select and fill out the following that apply to you today.
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I am here for DEPRESSION.
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In the last 2 weeks, how often have you felt the following?
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Mood: low mood, depressed, or hopeless?
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Anergy / little to no energy?
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Poor self-esteem, negative ego-centrism, hopelessness?
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Concentration trouble: reading news? watching TV?
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Appetite: poor appetite / overeating?
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Little interest or pleasure in doing things?
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Insomnia or Hypersomnia?
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Thoughts of death or hurting yourself?
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Feeling in slow motion, or restless?
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Impairment: how difficult has this made things?
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SCORE SUM (clinician only)
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I am here for ANXIETY.
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In the last 2 weeks, how often have you felt the following?
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1. Feeling nervous, anxious, or on edge?
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2. Not being able to stop or control worrying?
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3. Worrying too much about different things?
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4. Trouble relaxing?
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5. Being so restless that it's hard to sit still?
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6. Becoming easily annoyed or irritable?
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7. Feeling afraid as if something awful might happen?
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SCORE SUM (clinician only)
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I am here for KETAMINE INFUSION.
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Ketamine Rapid Action Dissociative Scale (K-RADS)
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Regarding THE LAST 48 hours, check the box that best represents the amount of time you felt the following way:
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1. I have little interest or pleasure in doing things that I would normally enjoy.
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2. I’ve felt down, depressed, or abnormally irritable.
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3. I have trouble falling or staying asleep, or I’ve been sleeping too much.
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4. I’ve felt abnormally tired or like I’ve had little energy
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5. I’ve felt bad about myself, like I am a failure or have let myself or my family down
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6. I have trouble concentrating on things like reading a newspaper or watching TV
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7. I’ve felt so fidgety / restless that I’ve been moving around much more than usual
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8. I have thoughts that I would be better off dead, or of hurting myself in some way
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9. I’ve found myself avoiding people, places, or things that are uncomfortable or remind me of troublesome memories/events
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10. I’ve felt my anxiety physically such as rapid heartbeat, sweating, or tremulousness
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11. I restrict eating, exercise heavily, compensate in other ways (i.e. laxatives or purge) to maintain body image/lose weight
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12. I have recurrent unwanted thoughts, urges, or impulses
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13. I find myself engaging in repetitive / checking behaviors to relieve my anxieties
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Regarding THE LAST 48 hours, check the box that best represents the amount of pain you felt:
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14. On a scale from 0 to 10 rate the LEAST pain you’ve experienced in the last 48 hours
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15. On a scale from 0 to 10 rate the MOST pain you’ve experienced in the last 48 hours
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16. On a scale from 0 to 10 rate the AVERAGE pain you’ve experienced in the last 48 hours
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17. On a scale from 0 to 10 rate the CURRENT pain you’re experiencing at this moment
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Regarding THE LAST 48 hours, check the box that best represents how limited you’ve been by the symptoms and pain rated above
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18. The symptoms and/or pain have disrupted my work/school work
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19. The symptoms and/or pain have disrupted my social life / leisure activities:
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20. The symptoms and/or pain have disrupted my family life / home responsibilities:
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Post-Infusion Dissociative Assessment
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During the active phase of the infusion, check the box that best represents how you felt:
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21. Time / events seemed to move in slow motion
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22. Things / events seemed unreal, as if I was in a dream
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23. I felt like I was looking at things from outside of my own body
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24. I felt like my my sense of my own body changed, as if I was larger or smaller than normal
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25. People appeared motionless, dead, or mechanical
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26. Objects looked different than I expected, as if distorted
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27. Colors appeared much lighter or more vivid than normal
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28. I felt confused about who I am
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29. I felt like I spaced out or lost track of what was going on
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30. I felt like sounds nearly disappeared or were much stronger than I would’ve expected
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Scoring Worksheet, Recommendations
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1. Mental Health Score
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Add questions 1-13 and report the sum here (maximum possible 39):
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Depressive Subscore (1-8) (maximum possible 24):
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Anxiety Subscore (2,3,4,6,7) (maximum possible 15):
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Panic Subscore (9,10) (maximum possible 6):
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PTSD Subscore (1-10) (maximum possible 30):
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OCD Subscore (12-13) (maximum possible 6):
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Eating Disorder (11) (maximum possible 3):
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2. Pain Score
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Add questions 14-17 and report the sum here (maximum possible 40):
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3. Dysfunction Score
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Add questions 18-20 and report the sum here (maximum possible 30):
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4. Dissociation Score
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Add questions 21-30 and report the sum here (maximum possible 40):
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Last Infusion #:
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Last K-RADS MH Score:
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Last K-RADS Pain Score:
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Last K-RADS Sum Score:
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Last Dysfunction Score:
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Last Dissociation Score:
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This Infusion #:
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New K-RADS MH Score:
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New K-RADS Pain Score:
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New K-RADS Sum Score:
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New Dysfunction Score:
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New Dissociation Score:
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Reference Guides
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Recommended Algorithms
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Designs and Domains
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TMS Treatment
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1) Do you have epilepsy?
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If yes, please specify
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2) Have you ever had a convulsion or a seizure?
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If yes, please specify
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3) Does someone in your family have epilepsy?
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If yes, how are you related to this person?
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4) Have you ever lost consciousness without any known reason?
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If yes, please describe when and how this occurred
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5) Have you ever had a severe head trauma?
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If yes, please specify
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6) Have you ever had a stroke?
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If yes, please specify
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7) Have you ever undergone surgery to your head?
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If yes, please specify
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8) Do you have any of the following implants in your body?:
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(metal) Plates and/or screws
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Vascular clips
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Artificial Heart valve
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Metallic splinters/shrapnel/etc.
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Pacemaker
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Insulin pump
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Internal hearing aid (cochlear implant)
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Any other implant not mentioned above
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If you answered “yes” to any of the questions above, please specify:
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9) Do you have any deviations of the spinal cord, bone marrow,
or ventricular system (spaces in the brain filled w/ liquid)?
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If yes, please specify:
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10) Do you have any hearing disabilities or ringing in your ears?
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If yes, please specify
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11) Have you ever (at present or in the past) suffered from a brain-related, neurological illness?
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If yes, please specify:
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12) Do you suffer from frequent severe headaches?
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If yes, please describe how often, and on which occasions:
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13) Are you currently under any form of medical treatment?
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If yes, please specify
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14) Are you currently taking antibiotics (a medication that helps alleviate bacterial infections)?
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If yes, please specify:
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15) Do you ever take antihistamines (anti-allergy medication)?
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If yes, how often and when was the last time you took them?
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16) Are you taking any other medications not mentioned above?
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If yes, please list:
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17) Do you have a chronic illness/disorder?
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If yes, please specify
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18) Have you ever (at present or in the past) had a psychiatric-based illness/disorder?
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If yes, please specify
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19) Does someone in your family have a psychiatric-based illness/disorder?
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If yes, please specify
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How are you related to this person?
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20) Have you used any recreational drugs during the past year (such as marijuana, ecstasy, cocaine, etc.)
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If yes, please specify:
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21) Have you ever suffered from substance dependence or abuse?
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If yes, please specify
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22) Do you averagely consume more than 3 alcoholic units a day?
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23) Do you have sleeping problems?
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If yes, please specify
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24) Are you pregnant, or is there a chance that you might be?
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25) Have you ever undergone an MRI for clinical purposes?
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If yes, did any problems occur during scanning?
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If yes, please specify
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26) Have you ever undergone TMS?
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If yes, have you ever had an adverse reaction to TMS?
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If yes, please specify
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