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Meet the Team
Patient and Family Education Section
Ketamine
Patient Portal
Insurance and Payment
Intake Form
Contact us
Home
Resources
Conditions Treated
Quick Tips
Local Community Resources
Meet the Team
Patient and Family Education Section
Ketamine
Patient Portal
Insurance and Payment
Intake Form
Contact us
patient information sheet
Name
*
First Name
Last Name
Email
*
Gender
Female
Male
Other
DOB
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Cell Phone
(###)
###
####
Social Security Number
Medicare ID Number
Secondary Insurance
ID Number
Prescription Plan
ID Number
Line
Name of primary contact
Relationship to the patient
Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Name of secondary contact
Relationship to the patient
Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Line
Referred by
Name of primary care provider
Reason for this consultation
Line
Patient's place of birth
Education level
Military service
Type of employment
If retired, when
MM
DD
YYYY
Marital / Relationship status & How long
Children and ages (seperated by a comma)
Parents, age & cause of death (if applicable)
Siblings, age & cause of death (if applicable)
Mentionable instances of family psychiatric history
If the patient has seen a psychiatrist or neurologist before, why?
Medical history (e.i. heart, lungs, thyroid, blood, arthritis, diabetes, hearing loss, vision. issues, stroke, lyme disease, COVID-19, head trauma, etc.)
Hospitalizations
MRI or CT scan history, where and when (if applicable)
Drinking quantity and history
Smoking quantity and history
Cannabis quantity and history
Check activities that the patient requires help with
Walking
Bathing
Dressing
Paying bills
Cooking
Laundry
Cleaning
Taking medication
Shopping
Who helps with these activities?
Check any other areas the patient is having trouble with
Sleep
Apetite
Energy
Interest
Motivation
Concentration
Boredom
Memory
Tearfulness
Feelings of emptiness
Guilt
Helplessness
Irritability
Hopelessness
Delusions
Thoughts of suicide
Suspiciousness
Hallucinations
Agitation
Aggression
Impulsiveness
Getting lost
Losing things
Fearfulness
Social withdrawl
Repetitive actions
Restlessness
Pacing or wandering
Are you basically satisfied with your life?
Yes
No
Have you dropped many of your interests and activities?
Yes
No
Do you feel your life is empty?
Yes
No
Do you often get bored?
Yes
No
Are you in good spirits most of the time?
Yes
No
Are you afraid something bad is going to happen to you?
Yes
No
Do you often feel helpless?
Yes
No
Do you prefer to stay at home or going out and doing new things?
Going out
Staying in
Do you feel that you have more memory problems than most
Yes
No
Do you think it's wonderful to be alive now?
Yes
No
Do you feel worthless in your current state?
Option 1
Option 2
Do you feel full of energy?
Yes
No
Do you feel your situation is hopeless?
Yes
No
Do you think most people are better off than you?
Yes
No
Name of person completing this form
Relationship to the patient
I understand that my meetings maybe recorded and summarized by automated tools.
Thank you!
