Ketamine-Assisted Psychotherapy

Name *

First Name

Last Name

Phone *

(###)

###

####

Metabolic/Endocrine Issues *

Hyper/Hypothyroidism

Yes

No

Kidney or Liver Disease *

Yes

No

Cardiovascular Issues *

High Blood Pressure, Heart Attack, Heart Disease, Hypertension

Yes

No

Respiratory Issues *

Asthma, Sleep Apnea, Pulmonary Hypertension

Yes

No

Substance Abuse Disorder *

Alcohol, Marijuana, Cocaine, Ketamine, Methamphetamines, Heroine

Yes

No

Seizure Disorder *

Yes

No

Stroke *

Yes

No

Traumatic Brain Injury *

Yes

No

Depression: *

Self

Family

Significant Other

None

PTSD *

Self

Family

Significant Other

None

Schizophrenia *

Self

Family

Significant Other

None

Suicidality *

Self

Family

Significant Other

None

Anxiety and/or Panic Attacks *

Self

Family

Significant Other

None

OCD *

Self

Family

Significant Other

None

Have you had any history of problems with anesthesia? *

Yes

No

Are you pregnant or could you be? Nursing? *

Yes

No