New Patient Intake Questionnaire

New Patient Intake Questionnaire
Date of Submission

YearMonthDay
Date
This form must be filled out in one (1) sitting; please do not try to save and come back to it later - you will have to redo the entire form.

Approximate completion time ~ 15 minutes

Please fill out this intake form so our clinical and administrative team can begin to assess your treatment protocol.

We typically respond to this form within 24 hours of receiving it.

We look forward to supporting you!
What kind of support are you looking for?

I feel healthy and want to keep it that way by building/maintaining my wellbeingI'm a busy professional and want to build/maintain my physical and mental resilienceI want to boost my athletic performanceI feel achy and tired a lotI'm struggling with depression and/or anxietyI want help with drug/alcohol addiction recovery and withdrawal managementI experience chronic pain and am wanting reliefI'm struggling with mood swings and general motivation
In your own words, please briefly describe why you are seeking treatment? What are you struggling with? What are you hoping these treatments will change?
What is your timeline/sense of urgency?

As soon as possible (Critical/Emergent)Some time in the next week (Urgent)Some time in the next 2 weeks (Somewhat Urgent)Some time this month (Soon)Some time in the next 3 months (Not Urgent)
How did you find out about CIT Clinics?

I was referred by a friend/family memberI was referred by my mental health professional (psychiatrist, therapist, social worker, etc.)I was referred by my doctor (primary care physician, specialist, etc.)Colleague/Word of MouthI did a Google searchI saw an online advertisement/linkI used a search engine other than GoogleApple MapsLinkedInFacebookYelpNextdoor.comVeterans Administration ReferralYouTube and/or 15 Minutes of PositivityRedditMarin MagazineOther
Name of person referring you
Personal & Contact Information
Name*

First NameLast Name
Preferred Name
Please upload a headshot photo of yourself.
Email*
example@example.com
Mobile Phone Number*
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Height
Weight
Birth Sex

FemaleMaleOther
Gender

FemaleMaleNon-binaryUnsurePrefer not to sayAnother gender not listed here
Pronouns

She/HerHe/HimThey/ThemOther
Medical History
Pregnancy/Menstruation Info
Are you pregnant?

YesNo
Are you breastfeeding?

YesNo
When was your last menstrual period?

MonthDayYear
Date
Medical conditions

Abdominal painAbnormal bleeding/clotting disorderAcid refluxAnemiaAsthmaBleeding DisordersBone/joint disordersChest pains/anginaChronic painCognitive challengesCongestive heart failureCOPD/Emphysema/Chronic BronchitisDementiaDiabetesDifficulty exercisingDizziness/faintingGlaucomaGynecologic issuesHeadachesHeart attackHeart diseaseInterstitial cystitisIrregular heart rhythmKidney problemsLiver problemsMuscle disordersNausea/vomitingNumbness/tinglingGI conditionsHypertensionOn a blood thinner medicationPacemakerSeizuresStroke/TIAThyroid issuesUnsteady gaitUsing home oxygenVisions/voicesVocal ParalysisOther
Please list any other medical conditions not noted above and/or explanations of the conditions above that you feel would be helpful for us to know.
What prescription medications are you currently taking?
What over-the-counter medications, supplements, herbs, etc. are you currently taking?
Please list 1) names, 2) conditions being used for, 3) dose 4) frequency of use
If you have one, please upload a copy of your medication list.

Cancelof
Surgeries & Anesthesia
Previous surgeries
please list 1) the type of surgery, 2) surgery date, 3) the underlying condition being treated and 4) outcome/success
Have you or any direct family members ever had a serious adverse reaction to anesthesia?

YesNo
What was the adverse reaction and to whom did it happen?
Allergies
Do you have any allergies?

YesNo
What allergies do you have?
List 1) known allergies and 2) their severity
Tobacco
Do you use any tobacco products?

YesNo

Other tobacco products?
List 1) type of products and 2) frequency of use
Alcohol
Do you drink alcohol?

YesNo

Recreational Drugs & Psychedelics
Have you ever used recreational drugs and/or psychedelics?

YesNo

List the dates of use for any of the compounds/drugs listed above. Please note, for your safety it is important that we are aware of this information so we may prevent/manage any possible contraindications. For example (but not limited to): Adderall, Valium, Ativan, etc.
Please list 1) name of substance, 2) date last taken
Other recreational drugs & psychedelics not listed above?
Please list 1) name of substance, 2) date last taken
Chronic Pain
Are you currently experiencing chronic pain?

YesNo
Do you currently have a chronic pain specialist/healthcare provider?

YesNo
Chronic pain specialist/provider name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Chronic pain specialist/provider Phone Number
Chronic pain specialist/provider email
example@example.com
Primary Care Provider
Do you currently have a primary care provider?

YesNo
Primary care provider name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Primary care provider phone number
Format: (000) 000-0000.
Primary care provider email
example@example.com
Prior Ketamine Treatment Experience
Are you currently receiving ketamine treatments elsewhere, or have you in the past 3 years?

YesNo
What type of ketamine treatment did you receive?

Intravenous (IV)Intramuscular (IM)Intranasal (IN)Oral/SublingualOther
When did/are you receive(ing) this treatment?
Where did you receive this treatment?   Clinic Name
Clinic/Doctor's Phone Number:      Phone Number
Clinic/Doctor's Email:   Email
Mental Health Conditions

Are you experiencing any of the following?

Rows	None	Some	Often	Chronic
Anxiety
Depression
PTSD

Have you ever received a formal diagnosis from a psychiatric provider?

YesNo
What is/was the official diagnosis?

DepressionAnxietyPTSDOther
Have you ever been formally diagnosed with any psychiatric condition with a psychotic component (ie. schizophrenia, schizoaffective disorder)?

YesNo
Mental Health Provider
Mental health provider type

PsychiatristTherapist/PsychologistSocial WorkerOther
Psychiatrist name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Psychiatrist phone number
Format: (000) 000-0000.
Psychiatrist email
example@example.com
Therapist/Psychologist name
IMPORTANT: We may need to contact this provider in order to evaluate the safety and efficacy of your treatments. Please provide their full name and complete contact information so we can reach out to them. You will be asked to sign a Medical Records Release Authorization, giving us permission to discuss your health information with them.
Therapist/Psychologist phone number
Format: (000) 000-0000.
Therapist/Psychologist email
example@example.com
Psychiatric Medications
Are you currently taking any prescription psychiatric medications?

YesNo
What psychiatric medications are you currently taking?

AntidepressantsAntipsychoticsMood stabilizersAntianxiety agentsStimulantsOther
List other psychiatric medications
please list 1) name of medication, 2) dose and 3) frequency of each medication you are taking.
Suicidal Ideations
Have you ever attempted suicide?

YesNo
When was your last suicide attempt? (Year)
Are you currently suicidal?

YesNo
Addiction Treatment
Have you ever been treated for any addictions?

YesNo
What addiction(s) were you treated for?
When were you being treated for addiction?

CurrentlyLast yearLast 2- 5 yearsMore than 5 years ago
Addiction program/counselor name
Addiction program/counselor phone number
Format: (000) 000-0000.
Addiction program/counselor email
example@example.com
Health Insurance
Do you have health insurance?

YesNo
Health Insurance Provider

AetnaAnthem Blue Cross Blue ShieldBlue Shield of CaliforniaBrown & TolandCignaHealth NetKaiserMedicalMedicareMolina HealthcareOptumSharp HealhSutter HealthTricare/TriwestUnited HealthcareOther
Health Insurance Provider Name (old - do not delete or we will lose the data)
Health Insurance Plan/Type

HMOPPOEPOPOSOther
Please upload a photo of the front of your Insurance Card
Please upload a photo of the back of your Insurance Card
In Case Of Emergency Contact (ICE)
ICE Name

First NameLast Name
Relationship to you

SpousePartnerWifeHusbandDaughterSonMotherFatherFriendOther Family MemberNeighborWork ColleagueOther
Their Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Their Email
example@example.com
Summary Statement
If these treatments are successful, how are you hoping your life will change/improve? What are you hoping to be able to feel/do/experience that is currently unavailable to you? What are your hopes/wishes for the future?
Contact Type
Lead Status
Lead Source
Patient Attestation

By submitting this form, I certify that I have completed this Questionnaire to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges.I authorize a representative from CIT Clinics to contact me to discuss treatment options for my condition(s). I also understand that the staff of CIT Clinics may not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment. I also consent to receiving emails from CIT Clinics for marketing purposes and I may opt out at anytime in the future by unsubscribing from CIT Clinic's marketing list.
Should be Empty:

Rows	Not currently	Yearly	Monthly	Weekly	Daily
Cigarettes
Cigars/Cigarillos
E-cigarettes
Chewing tobacco

Rows	None	Daily	Weekly	Monthly
Beer
Wine
Hard alcohol/liquor

Rows	Never	Daily	This past week	This past month	This past year	Many years ago
Marijuana/Cannabis
MDMA/Molly
Psilocybin/Mushrooms
LSD/Acid
Ayahuasca
DMT/5-MeO-DMT
Cocaine
Methamphetamine
Heroin/Opium/Opioids
Ketamine
GHB

New Patient Intake Questionnaire

Personal & Contact Information

Medical History

Pregnancy/Menstruation Info

Surgeries & Anesthesia

Allergies

Tobacco

Alcohol

Recreational Drugs & Psychedelics

Chronic Pain

Primary Care Provider

Prior Ketamine Treatment Experience

Mental Health Conditions

Mental Health Provider

Psychiatric Medications

Suicidal Ideations

Addiction Treatment

Health Insurance

In Case Of Emergency Contact (ICE)

Summary Statement

Patient Attestation