Ketamine Infusions for Depression & Pain • Free Consultations for New Patients • 850-906-5049 PATIENT PORTAL HEALTH HISTORY QUESTIONNAIRE Please complete the following forms to allow us to schedule your assessment MEDICAL HISTORY QUESTIONNAIRE RELEASE OF INFORMATION Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Weight(Required)PhoneEmail Referred by Contact Number for Referral Source Relationship to Patient Do you have a Healthcare Power of Attorney?(Required)(*if yes, include copy of document) Yes No File(Required)Max. file size: 300 MB.Are you currently under the care of a mental health provider (i.e., psychiatrist, psychologist, counselor)?(Required) Yes No Not applicable Name of Provider(Required)If not applicable, please put "Not Applicable" or "N/A" First and Last Type(Required)If not applicable, please put "Not Applicable" or "N/A" Current Frequency of Treatment(Required)If not applicable, please put "Not Applicable" or "N/A" How long have you been under the care of your current provider?(Required)If not applicable, please put "Not Applicable" or "N/A" For how long have you experienced depressive symptoms?(Required)If not applicable, please put "Not Applicable" or "N/A" Have you been diagnosed with any type of mental illness?(Required) Yes No Not Applicable Diagnosis(Required)If not applicable, please put "Not Applicable" or "N/A" Have you been hospitalized for symptoms related to your depression?(Required) Yes No Not Applicable Date Facility Do you have thoughts of suicide?(Required) Yes No Not Applicable Have you attempted suicide?(Required) Yes No Not Applicable Describe your support system (family, friends, support group, church, etc.):(Required)If not applicable, please put "Not Applicable" or "N/A"Describe any treatments or practices you have tried, in an effort to alleviate your depression, including exercise, meditation, etc.(Required)If not applicable, please put "Not Applicable" or "N/A"Military service?(Required) Yes No Not Applicable Branch Period(s) of service Did service include combat?(Required) Yes No Not Applicable Occupation Marital Status History of smoking or tobacco use?(Required) Yes No Not applicable Amount per day For how many years? If you quit, when did you quit? Do you drink alcohol?(Required) Yes No Not Applicable How many drinks per week? Do you have any medical problems? Click all that apply(Required) Hypertension/high blood pressure GERD/reflux Diabetes Hypercholesterolemia/high cholesterol Hypothyroidism None List any other medical problemsUse the plus sign to list more surgeriesYear Add RemoveType of Surgery Add RemoveCURRENT MEDICATIONS(Required)Please list dose and frequency of any medications you are currently taking. If not applicable, please put "Not Applicable" or "N/A":ALLERGIES(Required)List medication allergies, if any. If not applicable, please put "Not Applicable" or "N/A":Are you allergic to latex?(Required) Yes No I don't know Not Applicable Allergic to iodine or shellfish?(Required) Yes No I don't know Not Applicable Do you have biological family members who have major medical issues, or who have been diagnosed with depressive or anxiety disorders?(Required) Yes No Not Applicable Mother Father Sibling Other Click any of the following that belong to you:General(Required) Unanticipated Weight Loss Unanticipated Weight Gain General weakness Fevers Fatigue Night sweats None Select AllSkin / Hematologic(Required) Rashes Changes in moles or birthmarks Bleeding that does not stop Skin lumps Sores Easy bruising or bleeding Blood transfusion Color changes None Select AllHEAD, NECK, EARS, EYES, THROAT(Required) Headaches Head injury Glasses Contact lenses Eye pain Eye redness Vision problems Glaucoma Cataracts Hearing Loss Hearing aides Ringing in ears Ear infections Nasal congestion Hay fever Seasonal allergies Nosebleeds Sinus trouble Bleeding gums Toothaches Dentures Dry mouth Hoarseness Difficulty swallowing Mouth sores Lumps in neck Swollen glands Goiter Neck pain Neck stiffness Elevated Intracranial Pressure None Select AllRESPIRATORY(Required) Breast lumps Breast pain Nipple discharge Chronic cough Lung cancer Coughing up blood Wheezing Asthma Bronchitis Emphysema COPD Pneumonia Tuberculosis Shortness of breath Sleep apnea None Select AllCARDIAC(Required) Heart trouble Irregular heartbeat Heart attack Heart murmur Rheumatic fever Chest pain Palpitations Swollen ankles Angina Congestive Heart Failure Atrial Fibrillation Echocardiogram Treadmill stress test Cardiac stenting Cardiac catheterization Trouble breathing when lying flat None Select AllGASTROINTESTINAL(Required) Nausea Vomiting Vomiting blood Diarrhea Constipation Rectal bleeding Black, tarry stools Hemorrhoids Belly pain Jaundice Liver problems Cirrhosis Hepatitis Gall bladder trouble Irritable bowel Crohn’s disease Ulcerative colitis Hernia Ulcers Change in bowel habits None Select AllAny history of severe nausea with anesthesia?(Required) Yes No Not Applicable URINARY(Required) Frequency Kidney stones Kidney infection Burning or pain Blood in urine Urgency Dribbling Incontinence Frequent urinary tract infections Getting up at night to urinate None Select AllFOR MEN Sores Testicle pain Testicle lump Discharge from penis None Select AllFOR WOMEN Menstrual pain Heavy menses Vaginal lumps PMS Irregular menses Menopause Hot flashes Vaginal discharge Vaginal itching Vaginal dryness Vaginal sores None Select AllPeripheral Vascular/Musculoskeletal Gout Leg cramps Varicose veins Joint stiffness Leg clots Backache DVT (deep venous thrombosis) Muscle pains Arthritis Pain in calf with walking None Select AllCan you walk a mile?(Required) Yes No I don't know Not Applicable If not, why not? NEUROLOGIC/PSYCHOLOGICAL(Required) Fainting Blackouts Seizures Strokes TIA or mini-stroke Weakness Paralysis Numbness Tingling Loss of sensation Tremors Depression ADHD Anxiety None Select AllENDOCRINE(Required) Diabetes Hypothyroid Hyperthyroid Thyroid lumps Goiter Heat intolerance Cold intolerance Excessive sweating None Select AllDate(Required) MM slash DD slash YYYY