Massachusetts Ketamine Initial Questionnaire

Massachusetts Ketamine

Patient Health History
Identifying Information
Full Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Occupation
Gender*
Marital Status
Children?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*

Area CodePhone Number
Okay to leave voicemail?
E-mail
Welcome to Our Practice
How did you hear about our practice?*
What prompted you to seek ketamine infusion therapy?*
Emergency Contact
Emergency Contact Name/Relationship*
Phone Number*

Area CodePhone Number
Current Providers
Referring Provider Name and Phone #:
Current Psychiatrist/Prescriber Name and Phone#:
Current Therapist Name and Phone#:
Current Primary Care Doctor Name and Phone#:
Psychiatric History
Current Psychiatric Diagnoses:
History of Psychiatric Hospitalization? Please include dates.
Please describe current symptoms and duration:
History of psychotic symptoms/hallucinations?
History of self-injury?
History of suicidal ideation?
History of suicide attempts?
Trauma history?
Previous psychiatric medications/treatments tried (medications, therapies, TMS, ECT, etc. Please include any adverse reactions):
Family History?

Autism/Asperger'sAttention/ADHDDrug/Alcohol AbuseManic Depression/BipolarDepressionAnxiety DisorderSchizophrenia/PsychosisPsychiatric HospitalizationSuicideStealing/Legal ProblemsEpilepsy/SeizuresOther Neurological DisorderOther
Medical History
Do you have any adverse reactions and/or allergies to any drugs or medications?

NoYes
If yes, please give details
Please list current medical problems:
Current Medications (Please include all medications and supplements frequency and dosage):
Please indicate if you have had any of the following:

History Hypertension/High Blood PressureLow Blood PressureCardiovascular Disease/MIHeart ConditionAneurysmSyncope/FaintingKidney DiseaseUrinary/Bladder IssuesSeizure DisorderHead InjuryGI IssuesStrokeGlaucomaThryoid IssuesCancerAny Blood DisordersDiabetesAsthma/Breathing problemsHepatitisHIV/AidsLiver DiseasePregnant/NursingOther
How often do you exercise? Typical activity?
Past Surgical History and Dates:
Have you ever had an adverse reaction to anesthesia?
If yes please describe:
Substance Abuse History:

TobaccoAlcoholMarijuanaOpiatesHallucinogensCocaine/StimulantsOther
How many alcoholic drinks do you consume per day?
Any other information you feel is important for us to know?
By signing below you certify that you have completed this questionnaire accurately to the best of your knowledge.
Signature*

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Date

MonthDayYear
Date
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Identifying Information

Welcome to Our Practice

Emergency Contact

Current Providers

Psychiatric History

Medical History