vortexpsychiatry.com - INTAKE FORM

INTAKE FORM
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Your Full Name

First NameLast Name
Date of Birth

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Height
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Address

Street Address

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Postal / Zip Code
Phone Number (for private calls)
Please enter a valid phone number.
Occupation (if retired, previous work)
Emergency Contact (Name and Phone Number)
Primary Doctor (Name and Phone Number)
Psychiatrist (Name and Phone Number)
Referred by?
Past Medical History
Psychiatric History
Surgical History
Spiritual Beliefs and/or Religion
Current Medications
Allergies (and reactions)
Have you ever had an adverse reaction to anesthetic medications?

YesNo
If Yes, describe the event.
Have you ever had a psychiatric hospitalization?

YesNo
If Yes, describe the event.
Family Medical and Psychiatric History
Please check any use of the following drugs:

TobaccoAlcoholMarijuanaCocainePsilocybinMDMAAyahuascaLSDOther
If you have depression/anxiety/PTSD/chronic pain, please indicate the current average daily severity of the condition(s) on a scale of 1-10:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Please check below if you have any of these conditions:

Untreated hypertensionUntreated hyperthyroidismCongestive heart failureCardiac diseaseLiver diseaseKidney DiseasePersonal or family history of schizophreniaOther psychotic disorderPersonality disordersCurrent manic episodePregnancyBreastfeeding
What is your primary goal for ketamine infusions?
Anything else important that must be mentioned?
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