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?

Other
Medical History
Do you have any adverse reactions and/or allergies to any drugs or medications?
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:

Other
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:

Other
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
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Identifying Information

Welcome to Our Practice

Emergency Contact

Current Providers

Psychiatric History

Medical History