Hawaii Ketamine New Patient Intake Form

New Patient Intake Form
First Name
Last Name
Name

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Email Address
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Are you completing this form for yourself or on behalf of someone else?
How did you hear about us?
Name of Referrer

First NameLast Name
Other:
Please specify, it helps us, help more people!
Are you a Veteran or First Responder?*
Emergency Contact Person
Emergency Contact Person Phone #
Current Primary Care Doctor's Name
Current Primary Care Doctor's Phone #
Current Mental Health Clinician's Name and Specialty
i.e. Psychiatrist, Mental Health Nurse Practitioner
Current Mental Health Clinician Phone #
Current Therapist's Name and Specialty
i.e. Psychologist, Counselor / Social Worker/ LiCSW or PHD
Current Therapist Phone #
Pertinent Medical History
Please describe your co-existing conditions, such as high blood pressure, diabetes, treatment resistant depression, PTSD, etc...
Please describe your experience with pain management in the past. List what therapies you have tried, such as Physical Therapy, Prescription Medication, etc.
Please describe your experience with Mental Health Therapies in the past. List what therapies you have tried, such as Cognitive Behavioral Therapy, Prescription Medication, etc.
Have you or any other immediate family members ever experienced any adverse side effects after receiving anesthesia (laughing gas, lidocaine, etc.) and/or sedatives for surgery or any other use? If yes please list
Please list
Do you have any Allergies?
If "YES" to allergies, please list them and the reaction( i.e penicillin gives me a rash) :
Please list ALL of your Medical Diagnoses:
Please list ALL previous surgeries with the year the surgery was performed.
Mental Health History

Please complete the following information and our team will go through this in more detail with you at your Ketamine consultation.
Approximately when did your current depressive symptoms start?
Do you have any previous mental health hospitalizations?
What was the approximate date of your most recent mental health hospitalization?
How many mental health hospitalizations have you had?
Are you CURRENTLY under the care of a Psychiatrist or Psychiatric Nurse Practioner who prescribes you medication?
In the past, have you attended talk therapy with a therapist, counselor or Psychologist?
Do you CURRENTLY attend talk therapy with a therapist, counselor or Psychologist?
What is the approximate date that you last attended talk therapy?
Please Select ALL of your Current Symptoms
Depressed MoodLow EnergySuicidal ThoughtsSelf-Injurious BehaviorSelf-Injurious ThoughtsIncreased AppetiteDecreased AppetiteRestlessnessSleep DisturbanceImpaired ConcentrationFatigueLow MotivationMemory DeficitsExcessive WorryPanic attacksTalking or moving slowlyNightmaresDecreased need for sleepPhysical PainDifficulty relaxingIntrusive / unwanted thoughts
Excessive Alcohol UseDrug AbuseIllicit Drug UseAnorexiaBulimiaElevated or Euphoric MoodConfusionMuscle TensionSocial AnxietyRitualistic BehaviorsIsolationDecreased HygieneHearing voices or noises others can't hearHomicidal thoughtsUpset stomach / NauseaInability to workBinge eatingSeeing people or things that others can't seeFlashbacksExcessive energy
Family History

Do you have a family history of mental health issues?
Please list the family member(s) and the disorder(s)
Social History
Do you live alone or with others
If you live with others, who do you live with?
What is your occupation?
Employment Status?
Have you ever smoked cigarettes?
Currently?
How many packs per day?
How many years?
In the Past?
How many packs per day?
How many years?
When did you quit?
Vaping?
Marijuana?
If yes, How often?
Alcohol?
If yes, How often and how much?
Illicit drug use?
Have you ever considered yourself to have a problem with alcohol or drugs?
If yes, approximately how long has it been since you last used alcohol or drugs?
Antidepressants

Carefully examine the list below, please select both CURRENT and PREVIOUS medications tried:
Prozac (fluoxetine)Celexa (citalopram)Luvox (fluvoxamine)Zoloft (sertraline)Paxil (paroxetine)Lexapro (escitalopram)
Please include the Dosage and timeframes for the option(s) selected
Pristiq (desvenlafaxine)Effexor (venlafaxine)Fetzima (levomilnacipran)Cymbalta (duloxetine)Savella (milnacipran)
Please include the Dosage and timeframes for the option(s) selected
Tofranil (imipramine)Vivactil (protriptyline)Elavil (amitriptyline)Pamelor (nortriptyline)Anafranil (clomipramine)Doxepin (sinequan)Norpramin (desipramine)
Please include the Dosage and timeframes for the option(s) selected
Marplan (isocarboxazid)Parnate (tranylcypromine)Emsam (selegiline)Nardil (penelzine)
Please include the Dosage and timeframes for the option(s) selected
Wellbutrin (bupropion)
Please include the Dosage and timeframes for the option(s) selected
Viibryd (vilazodone)Deseryl / Oleptro (trazodone)Serzone (nefazodone)Trintellix (vortioxetine)
Please include the Dosage and timeframes for the option(s) selected
Spravato (esketamine)Auvelity (dextromethorphan & bupropionKetamineDesyrel / Oleptro (trazodone)Remeron (mirtzaipine)
Please include the Dosage and timeframes for the option(s) selected
Tegretol (carbamazepine)Depakote (valproate)Trileptal (oxcarbamazepine)LithiumLamictal (lamotrigine)Topax (topiramate)
Please include the Dosage and timeframes for the option(s) selected
Seroquel (quetiapine)Abilify (aripiprazole)Clozaril (clozapine)Prolixin (fluphenazine)Latuda (lurasidone)Rexulti (brexpiprazule)Vraylar (cariprazine)Geodon (ziprasidone)Zyprexa (olanzapine)Haldol (haloperidone)Invega (paliperidone)Risperdal (risperidone)Caplyta (lumateperone)
Please include the Dosage and timeframes for the option(s) selected
Ambien (zolpidem)Rozerem (ramelteon)Sonata (zaleplon)Restoril (temazepam)
Please include the Dosage and timeframes for the option(s) selected
Adderall (amphetamine salts)Strattera (atomoxetine)Concerta (methylphenidate)Ritalin (methylphenidate)Vyvanse (dextroamphetamine)
Please include the Dosage and timeframes for the option(s) selected
Xanax (alprazolam)Klonopin (clonazepam)Tranxene (clorazepate)Ativan (lorazepam)Valium (diazepam)BuSpar (buspirone)
Please include the Dosage and timeframes for the option(s) selected
Please list any other medications not on this list:
Pain Inventory Self Assessment
Do You Suffer From Pain?
YesNo

Pain Management History

Rows	Helped a Little	Helped a lot	Did Not Help at All
Prescription Medication
Opioids
Physical Therapy
Trigger Point Injections
Surgical Implants
TENS / Bioelectric Therapy
Psychological Therapy
Mind-Body Therapies
Accupuncture
Alternative Therapies

Please include additional information about your pain management experiences and/or describe alternate therapies below.
On the diagram, Select the areas where you feel pain. Check the box below for the area that hurts the most.
#1 Shoulder Pain#2 Abdominal Pain#3 Arm Pain#4 Knee / Leg Pain#5 Head / Neck Pain#6 Back Pain#7 Higher Leg Pain#8 Ankle / Feet Pain
2. Please rate your pain by marking the box beside the number that best describes your pain at its worst in the last 24 hours.

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1 is No Pain, 10 is Pain As Bad As You Can Imagine
3. Please rate your pain by marking the box beside the number that best describes your pain at its least in the last 24 hours.

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1 is No Pain, 10 is Pain As Bad As You Can Imagine
4. Please rate your pain by marking the box beside the number that best describes your pain on average.

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1 is No Pain, 10 is Pain As Bad As You Can Imagine
5. Please rate your pain by marking the box beside the number that tells how much pain you have right now.

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1 is No Pain, 10 is Pain As Bad As You Can Imagine
7. What treatments or medications are you receiving for your pain?
0%15%25%35%45%55%65%75%85%95%
9. Select the number that describes how, during the past 24 hours, pain has interfered with your:
A. General Activity

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1 is Does Not Interfere, 10 is Completely Interferes
B. Mood

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1 is Does Not Interfere, 10 is CompletelyInterferes
C. Walking ability

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1 is Does Not Interfere, 10 is Completely Interferes
D. Normal Work (includes both work outside the home and housework)

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1 is Does Not Interfere, 10 is Completely Interferes
E. Relations with other people

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1 is Does Not Interfere, 10 is Completely Interferes
F. Sleep

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1 is Does Not Interfere, 10 is Completely Interferes
G. Enjoyment of life

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1 is Does Not Interfere, 10 is Completely Interferes
PHQ-9

Patient Health Questionnaire-9- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not Difficult at allSomewhat DifficultVery DifficultExtremely Difficult
Result (office use only)
GAD-7

Generalized Anxiety Disorder -7- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not at allSeveral daysMore than half the daysNearly every day
Not Difficult at allSomewhat DifficultVery DifficultExtremely Difficult
Result (office use only)
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New Patient Intake Form

Pertinent Medical History

Mental Health History

Please Select ALL of your Current Symptoms

Family History

Social History

Antidepressants

Pain Inventory Self Assessment

On the diagram, Select the areas where you feel pain. Check the box below for the area that hurts the most.

PHQ-9

GAD-7