{"id":8461,"date":"2023-04-14T13:55:31","date_gmt":"2023-04-14T13:55:31","guid":{"rendered":"https:\/\/ketamineonline.us\/?page_id=8461"},"modified":"2023-04-28T13:20:30","modified_gmt":"2023-04-28T13:20:30","slug":"initial-questionaire","status":"publish","type":"page","link":"https:\/\/ketamineonline.us\/?page_id=8461","title":{"rendered":"INITIAL QUESTIONAIRE"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8461\" class=\"elementor elementor-8461\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6804093 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6804093\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-75374a3\" data-id=\"75374a3\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-730b6f6 elementor-widget elementor-widget-shortcode\" data-id=\"730b6f6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-9041\"><form id=\"wpforms-form-9041\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"9041\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F8461\" data-token=\"35254b38fc751a5731189f94a944d53e\" data-token-time=\"1785106109\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-9041-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-9041-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-9041-field_0-error\" required><label for=\"wpforms-9041-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-9041-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-9041-field_0-last-error\" required><label for=\"wpforms-9041-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-9041-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-9041-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-9041-field_1-error\" required><\/div><div id=\"wpforms-9041-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_3\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-9041-field_3\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-9041-field_3-error\" required><\/div><div id=\"wpforms-9041-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_4\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9041-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" aria-errormessage=\"wpforms-9041-field_4-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-9041-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_6\">What is Your Mental Health Diagnosis?<\/label><input type=\"text\" id=\"wpforms-9041-field_6\" class=\"wpforms-field-large\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-9041-field_6-error\" ><\/div><div id=\"wpforms-9041-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_7\">What is Your Medical History Diagnosis? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9041-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-9041-field_7-error\" required><\/div><div id=\"wpforms-9041-field_9-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_9\">Please list all drugs you are currently taking &amp; dosage.<\/label><textarea id=\"wpforms-9041-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-9041-field_9-error\" ><\/textarea><\/div><div id=\"wpforms-9041-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_8\"> For What Condition are you considering Ketamine Therapy?<\/label><input type=\"text\" id=\"wpforms-9041-field_8\" class=\"wpforms-field-large\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-9041-field_8-error\" ><\/div><div id=\"wpforms-9041-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_10\">What symptoms are you having and how severe are they?<\/label><input type=\"text\" id=\"wpforms-9041-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-9041-field_10-error\" ><\/div><div id=\"wpforms-9041-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_11\">Have you tried other treatments for your disease, and if so, what were the results?<\/label><input type=\"text\" id=\"wpforms-9041-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-9041-field_11-error\" ><\/div><div id=\"wpforms-9041-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_12\">Have you ever had an adverse response to ketamine or any other medications?<\/label><input type=\"text\" id=\"wpforms-9041-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-9041-field_12-error\" ><\/div><div id=\"wpforms-9041-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_13\"> Any family history of schizophrenia\/Psychosis?<\/label><input type=\"text\" id=\"wpforms-9041-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-9041-field_13-error\" ><\/div><div id=\"wpforms-9041-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_14\">Are you pregnant or breastfeeding?<\/label><input type=\"text\" id=\"wpforms-9041-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-9041-field_14-error\" ><\/div><div id=\"wpforms-9041-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_15\">Any use of drugs or alcohol? Please list frequently and amount.<\/label><input type=\"text\" id=\"wpforms-9041-field_15\" class=\"wpforms-field-large\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-9041-field_15-error\" ><\/div><div id=\"wpforms-9041-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_17\">Please list all allergies:<\/label><textarea id=\"wpforms-9041-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-9041-field_17-error\" ><\/textarea><\/div><div id=\"wpforms-9041-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_16\">History of suicidal ideations?<\/label><input type=\"text\" id=\"wpforms-9041-field_16\" class=\"wpforms-field-large\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-9041-field_16-error\" ><\/div><div id=\"wpforms-9041-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_18\">History of suicidal attempts?<\/label><input type=\"text\" id=\"wpforms-9041-field_18\" class=\"wpforms-field-large\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-9041-field_18-error\" ><\/div><div id=\"wpforms-9041-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_19\">History of trauma?<\/label><input type=\"text\" id=\"wpforms-9041-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-9041-field_19-error\" ><\/div><div id=\"wpforms-9041-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_20\">Do you have a psychiatrist?<\/label><input type=\"text\" id=\"wpforms-9041-field_20\" class=\"wpforms-field-large\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-9041-field_20-error\" ><\/div><div id=\"wpforms-9041-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_21\">Do you have a therapist?<\/label><input type=\"text\" id=\"wpforms-9041-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-9041-field_21-error\" ><\/div><div id=\"wpforms-9041-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_22\">Do you have a primary care provider?<\/label><input type=\"text\" id=\"wpforms-9041-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-9041-field_22-error\" ><\/div><div id=\"wpforms-9041-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_23\">Do you have fresh lab work within the past year?<\/label><input type=\"text\" id=\"wpforms-9041-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-9041-field_23-error\" ><\/div><div id=\"wpforms-9041-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_24\">Do you plan on using any health insurance?<\/label><input type=\"text\" id=\"wpforms-9041-field_24\" class=\"wpforms-field-large\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-9041-field_24-error\" ><\/div><div id=\"wpforms-9041-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_25\">Are you willing to follow the treatment plan?<\/label><input type=\"text\" id=\"wpforms-9041-field_25\" class=\"wpforms-field-large\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-9041-field_25-error\" ><\/div><div id=\"wpforms-9041-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-9041-field_26\">Do you have any questions  or concerns about ketamine therapy?<\/label><input type=\"text\" id=\"wpforms-9041-field_26\" class=\"wpforms-field-large\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-9041-field_26-error\" ><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"9041\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/ketamineonline.us\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F8461\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-9041\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/ketamineonline.us\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container 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