Medical History Form

Full Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Gender*

MaleFemale
Height*
Weight*
Pounds (lb)
Contact Information

How may we best get in touch with you?
Email*
example@example.com
Phone Number*
Home or Mobile?*

HomeMobile
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact

In case of an emergency, who should we contact?
Full Name

First NameLast Name
What is their relationship to you?*
Relationship
Phone Number (Home or Mobile)*
Primary Health Care Provider*

First NameLast Name
Mental Health Care Provider (If Any)

First NameLast NameSpeciality
Additional Mental Health Care Provider

First NameLast NameSpeciality
Pain Management Provider (If Any)

First NameLast NameSpeciality
Insurance Information
Please list all health insurances, including Medicaid/Medicare:
Psychiatric History

Tell us a little about your mental health history
What are your current psychiatric diagnoses?
What are your current pain diagnoses?

0/400
Have you previously had ketamine infusions?*

YesNo
If you answered yes, please upload your most recent ketamine infusion record(s).

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Do you currently suffer from suicidal thoughts?*

YesNo
If so, how long often?
Previous Suicide Attempts (if any)
What medications do you currently take?
Do you have any allergies?

0/400
Emergency Room Visits (Last 6 Months)

1000 words max0/400
In-Patient Admissions (Last 6 Months)

1000 words max0/400
Substance Use

Please indicate current use or use within the last 12 months:
Tobacco
Alcohol
Marijuana
Cocaine
Heroin
Other
General Medical History

Have you had surgery before? Visited the ER? Received other therapies?
Describe any other medical problems that you have

1000 words max0/400
Surgical History

1000 words max0/400
Have you ever received electroconvulsive therapy (ECT)?*

YesNo
Do you experience hallucinations?*

YesNo
History of difficult IV access*

YesNo
Review of Systems
Eyes*

NoneBlurry/Double VisionGlaucoma
Respiratory*

NoneCoughCoughing up bloodShortness of breathWheezingPainful breathing
Cardiovascular*

NoneChest PainShortness of breathPalpitations
Urinary*

NoneFrequencyUrgencyBurning or painBlood in urineBladder ulcerations
Vascular*

NoneHistory of blood clots
Neurologic*

NoneSeizuresStrokeMemory loss
Please verify that you are human*
Signature

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Contact Information

Emergency Contact

Insurance Information

Psychiatric History

Substance Use

General Medical History

Review of Systems