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IV Ketamine Consultation Note
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EIN/ NPI
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CPT
• • •
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Referred by:
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Chief Complaint:
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Date of Current Episode
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HPI
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HPI Symptoms:
• • •
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Current Rating Scales
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GAD-7
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PHQ- 9 Score:
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Discussion of Treatments:
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Past Psychiatric History:
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H/O Hypomania/Manic Episodes
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H/O Inpatient Hospitalizations:
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If H/O Inpatient Hospitalization, explain:
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H/O Suicide Attempts:
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If H/O Suicide Attempts, explain:
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H/O Addiction:
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If H/O Addiction, explain:
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Therapy
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Provider 1
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Dates:
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Type:
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Outcome:
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Family History:
• • •
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Past Medical History
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Additional Past Medical History
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Habits:
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Current Medications
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Past Medications
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Allergies:
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PE/Labs:
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Social History:
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Marital Status:
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Living Situation
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Lives with...
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Education:
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Employment:
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Father:
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Mother:
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Siblings:
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Mental Status Exam
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Appearance:
• • •
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Speech:
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Orientation:
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TP:
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Affect
• • •
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HI:
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Mood:
• • •
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Psychosis:
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SI:
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Diagnostic Impression:
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DI: Major Depressive Disorder
• • •
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DI: Bi-Polar
• • •
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DI: Other Disorders
• • •
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DI: (If not listed as favorite above)
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Assessment of Severity:
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Recommendations:
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Additional Recommendations
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Risks/Benefits
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