INITIAL QUESTIONAIRE

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Name

First

Last

Phone

Date of Birth

What is Your Mental Health Diagnosis?

What is Your Medical History Diagnosis?

Please list all drugs you are currently taking & dosage.

For What Condition are you considering Ketamine Therapy?

What symptoms are you having and how severe are they?

Have you tried other treatments for your disease, and if so, what were the results?

Have you ever had an adverse response to ketamine or any other medications?

Any family history of schizophrenia/Psychosis?

Are you pregnant or breastfeeding?

Any use of drugs or alcohol? Please list frequently and amount.

Please list all allergies:

History of suicidal ideations?

History of suicidal attempts?

History of trauma?

Do you have a psychiatrist?

Do you have a therapist?

Do you have a primary care provider?

Do you have fresh lab work within the past year?

Do you plan on using any health insurance?

Are you willing to follow the treatment plan?

Do you have any questions or concerns about ketamine therapy?

Ketamine Therapy