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)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Weight(Required)

Phone

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

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

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

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

Not Applicable

Date

Facility

Do you have thoughts of suicide?(Required)

Yes

Not Applicable

Have you attempted suicide?(Required)

Yes

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

Not Applicable

Branch

Period(s) of service

Did service include combat?(Required)

Yes

Not Applicable

Occupation

Marital Status

History of smoking or tobacco use?(Required)

Yes

Not applicable

Amount per day

For how many years?

If you quit, when did you quit?

Do you drink alcohol?(Required)

Yes

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 problems

Use the plus sign to list more surgeries

Year

Type of Surgery

CURRENT 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

I don't know

Not Applicable

Allergic to iodine or shellfish?(Required)

Yes

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

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

Skin / 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

HEAD, NECK, EARS, EYES, THROAT(Required)

RESPIRATORY(Required)

CARDIAC(Required)

GASTROINTESTINAL(Required)

Any history of severe nausea with anesthesia?(Required)

Yes

Not Applicable

URINARY(Required)

FOR MEN

Sores

Testicle pain

Testicle lump

Discharge from penis

None

FOR WOMEN

Peripheral Vascular/Musculoskeletal

Can you walk a mile?(Required)

Yes

I don't know

Not Applicable

If not, why not?

NEUROLOGIC/PSYCHOLOGICAL(Required)

ENDOCRINE(Required)

Diabetes

Hypothyroid

Hyperthyroid

Thyroid lumps

Goiter

Heat intolerance

Cold intolerance

Excessive sweating

None

Date(Required)