Esketamine Monitoring Log Form
Complete this form to document key observations and details for an esketamine treatment session.
Patient Initials
*
Session ID or Reference Number
*
Date of Treatment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Dose Administration
*
Hour Minutes
AM
PM
AM/PM Option
Pre-dose Vital Signs (BP, HR, SpOâ‚‚)
*
Pre-dose Mental Status/Observation
Post-dose Vital Signs (BP, HR, SpOâ‚‚)
*
Post-dose Mental Status/Observation
Symptoms or Adverse Events Observed
Dissociation
Nausea/Vomiting
Dizziness
Increased Blood Pressure
Sedation
Other
Clinician Notes / Additional Comments
Submit
Should be Empty: