Ketamine Participant Health Review Form v2

Fusion Medicine & Wellness LLC

Charlotte Charfen, M.D.
Ketamine Participant Health Review

Dr. Charfen believes deeply in the power of psychedelic medicine for personal healing and psycho-spiritual exploration. To safely and legally support your experience with Ketamine in this model, it is important that our medical team is made aware of any physical and mental health conditions, medications and habits that could affect your journey. This health review is designed to inform us of your past experience with psychedelics in general and any potential contraindications that might not be compatible with the Ketamine group model provided. Please complete this confidential questionnaire honestly and completely so that we can fully evaluate, support and determine if this setting is safe for you. A participant's spot is not guaranteed until the form is received and reviewed by Dr. Charfen and her medical team.
Which training are you interested in?*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Participant E-Mail*
example@example.com
Birthdate*

MonthDayYear
Pleae enter your birthdate.
Gender
Height (ft/in)
Weight (lbs)*
Participant Medical History
Please list any current medical conditions *
Please list any past surgeries and their dates *
If you have had surgery, did you ever have a reaction to anesthesia?

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you tend to be sensitive or insensitive to medications?*

SensitiveAverageInsensitive
Do you have a history of motion sickness or are you quick to nausea?*

YesNo
Do you have a known or suspected allergy to ketamine?*

YesNo
Do you have history of uncontrolled hypertension, stroke or cardiac disease (prior heart attack, cardiac stents or bypass surgery)*

YesNo
Do you have known renal or liver insufficiency or failure?*

YesNo
Have you ever been diagnosed or suspect you have any of the following medical conditions?*

Chest pain or anginaHeart arrhythmiaHeart FailureTraumatic brain injuryEpilepsy or seizure disorderMigrainesAny other type of Neurological disorderGlaucomaAsthma or COPDSleep ApneaCancerDiabetesNone of the above
Please elaborate on any conditions for which you answered "Yes":
Do you have any other medical concerns or information you wish to share with Dr. Charfen?
Mental Health History
Do you have a regular meditation practice?

YesSometimes/InfrequentlyNo
Do you have a significant past trauma history?

ExtensiveModerateLimitedNoneI don't know
Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?*

DepressionAnxietyPTSD (PostTraumaticStress Disorder)Schizophrenia or other psychotic conditionBipolar disorderObsessive CompulsiveDisorder (OCD)Borderline Personality DisorderSubstance Use Disorder or AddictionNone ApplyOther
How much psychotherapy have you completed?

ExtensiveLimitedNone
Have you ever experienced a psychiatric crisis?*

YesNo
Have you required antipsychotics (prescription or as needed by Emergency staff) or emergency administration of other mood-altering medications for the management of acute agitation*

YesNo
Please elaborate or share any mental health concerns here:
Medications & Supplements
Please list your current medications with dosing, including supplements*
Are you taking any of the following medications or supplements regularly?*

Anti-anxietyAnti-psychoticsMood StabalizersNarcoticsLamictalGabapentinBlood pressureCannabisAlcoholNone Apply
Please elaborate on any answers:
Please list any drug allergies*
Psychedelic Use
Have you used Ketamine or other psychedelic substances before? If so, please share brief details about your experience that you believe are applicable.*
Prior experience with Ketamine?*

None1-5 times6-11 times+11 times
Have you ever had any negative experiences or bad reactions to Ketamine or other psychedelic substances? If so, please give a brief description.*
Please describe your personal goals for using Ketamine:*
Which of the following do you consider your support network?*

Psychiatrist or ProviderTherapist or CounselorPsychedelic SocietyAlternative PractitionerTreatment ProgramChurch or religious organizationsPartner or Family MembersClose FriendsOther
If a mental health crisis occurred, how confident are you that your support network would be adequate to help you through it?*
Emergency Contacts

In the event of an emergency whom should we contact?
Emergency Contact #1*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Emergency Contact #2*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Thank you!

This questionnaire serves to inform us of any physical or mental health concerns that might not be compatible with the Ketamine experience in the group setting provided.

If there are no contraindications, you'll be contacted for further instructions to secure your spot in this limited training and retreat.

If any concerns arise from this questionnaire, Dr. Charfen may require more information, an interview or medical records before moving forward with your enrollment.

Should Dr. Charfen determine that your circumstances would be better served in a different setting, she will let you know right away.

We appreciate your time and understanding. Please watch for an email with further details.

With gratitude,

Dr. Charfen & Team
Should be Empty:

Fusion Medicine & Wellness LLC

Ketamine Participant Health Review

Participant Medical History

Mental Health History

Medications & Supplements

Psychedelic Use

Emergency Contacts