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Confirmation of name
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Confirmation of D.O.B.
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Confirmation of address
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Confirmation of physical location at the time of visit
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History of Present Illness:
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Location: Regarding mental status, location could correspond to domain (e.g., mood, thought process, perception, etc.):
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Duration: Initial onset of symptoms; how long symptoms last; most recent episode:
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Context: Psychosocial factors related to the problem:
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Associated signs and symptoms: What else is happening as a result of this (loss of function/drive/appetite/weight/libido):
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Modifying factors: What brings on or relieves the problem?
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Severity: Language that relates to how bad the problem is (e.g., “8 out of 10,” controlled, uncontrolled):
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Timing: Language that relates to when symptoms are experienced, such as in certain situations; time of day; do they come and go:
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Quality: Descriptive language (e.g., forgetful, depressed, disorganized, hallucinating):
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SI/HI [-]:
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SI/HI [+]:
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Past Medical/Family/Social History:
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Ketamine Exclusion Criteria:
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Do you have a ketamine allergy?
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Comments:
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Active ketamine abuse or dependence?
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Comments:
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Do you have a history of migraine headaches?
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Comments:
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Active alcohol or substance abuse or dependence?
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Comments:
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Do you have a history of opioid use disorder?
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Comments:
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Do you have any active psychotic or manic symptoms, or a history of a primary psychotic disorder?
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Comments:
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Do you have any active suicidal ideation with method, intent, or plan within the last month?
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Comments:
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Have you made any suicide attempts within the past year?
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Comments:
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Do you currently have uncontrolled high blood pressure?
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Comments:
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Do you have a history of congestive heart failure or other serious heart problems?
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Comments:
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Do you have severe breathing problems such as COPD?
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Comments:
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Do you have uncontrolled thyroid disease?
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Comments:
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Do you have uncontrolled elevated intra-ocular pressure such as glaucoma?
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Comments:
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Have you ever been diagnosed with a personality disorder?
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Comments:
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Do you have a history of elevated intracranial pressure?
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Comments:
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Are there any other serious medical illnesses not listed above?
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Comments:
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Are you currently taking Lamictal or lamotrigine?
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Comments:
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Are you pregnant, nursing, or currently trying to become pregnant?
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Comments:
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Are you at least 18 years old?
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Comments:
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Past Medical/Psych History:
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Past medical/surgical/injury history [-]:
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Past medical/surgical/injury history [+]:
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Medication allergies [-]:
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Medication allergies [+]:
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Current non-psychiatric meds [-]:
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Current non-psychiatric meds [+}:
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Past psychiatric diagnosis history [-]:
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Past psychiatric diagnoses [+]:
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Current psychiatric meds [-]:
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Current psychiatric meds:
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Past psychiatric medication trials:
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PDMP reviewed this visit
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History of suicidal attempts:
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History of suicidal attempts:
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History of SIB:
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History of SIB:
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History of A/V hallucinations:
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History of A/V hallucinations:
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History of psychiatric inpatient hospitalizations:
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History of inpatient hospitalizations: 1st, last and total number
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History of SA inpatient hospitalizations:
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History of SA inpatient hospitalizations:
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History of psychotherapy trials:
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History of psychotherapy trials:
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History of ECT trials:
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History of ECT trials:
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Family History:
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Family History of Mental Health or SA [-]:
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Family History of Mental Health or SA [+]:
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Comments:
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Social History:
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Adverse Childhood Experiences (ACEs):
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Adverse Childhood Experiences (ACEs):
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Are there any substances that you are actively using?
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List any substances that you are actively using?
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Are there any substances that you've tried or used in the past?
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List any substances that you've tried or used in the past?
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Are you currently using any of the following:
• • •
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Comments:
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Review of Systems:
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Cardiovascular [-]:
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Cardiovascular [+]:
• • •
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Cardiovascular Comments:
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Endocrine [-]:
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Endocrine [+]:
• • •
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Endocrine Comments:
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Gastrointestinal [-]:
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Gastrointestinal [+]:
• • •
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Gastrointestinal Comments:
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Genitourinary [-]:
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Genitourinary [+]:
• • •
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Genitourinary Comments:
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HEENT [-]:
|
HEENT [+]:
• • •
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HEENT Comments:
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Integumentary [-]:
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Integumentary [+]:
• • •
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Integumentary Comments:
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Musculoskeletal [-]:
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Musculoskeletal [+]:
• • •
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Musculoskeletal Comments:
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Neurological [-]:
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Neurological [+]:
• • •
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Neurological Comments:
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Respiratory [-]:
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Respiratory [+]:
• • •
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Respiratory Comments:
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Psychiatric [-]:
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Psychiatric [+]:
• • •
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Psychiatric Comments:
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Reproductive for women only: pregnancy
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Contraceptives:
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Last menstrual period
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Home Treatment Environment:
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Peer Treatment Monitor (PTM):
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Name of peer treatment monitor:
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Age of peer treatment monitor:
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Phone number of peer treatment monitor:
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Patient will provide PTM information to guide.
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PTM is required to do visual check on the client every 15 min, let the client know when an hour has passed
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PTM will be required to appear on camera during the first treatment to review his/her role with the guide.
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Home/Treatment Environment:
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Verify they have a private, secure, safe space for treatment
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Ideal setting criteria
|
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Patient should not drive after treatment until they have gotten a full night’s sleep
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Treatment environment:
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Assessment:
|
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Is the client appropriate for ketamine treatment?
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Patient disqualified for treatment
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Comments:
|
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Education:
|
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Blood Pressure/ Heart Rate Monitoring Education:
|
Eye mask/Journal:
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Ketamine:
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Zofran:
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Ketamine Side Effects:
• • •
|
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Safety/ Preparing to Take Ketamine:
• • •
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