Ketamine Infusion Therapy Screener

1

Your Name* This field is required.

First Name

Last Name

2

E-Mail* This field is required.

example@example.com

3

Birth Date* This field is required.

4

Gender* This field is required.

5

Over the last 2 weeks, how often have you been bothered by the following problems?

6

Little interest or pleasure in doing things* This field is required.

Not at all

Several days

More than half the days

Nearly every day

7

Feeling down, depressed or hopeless* This field is required.

Not at all

Several days

More than half the days

Nearly every day

8

Trouble falling asleep, staying asleep, or sleeping too much* This field is required.

Not at all

Several days

More than half the days

Nearly every day

9

Feeling tired or having little energy* This field is required.

Not at all

Several days

More than half the days

Nearly every day

10

Poor appetite or overeating* This field is required.

Not at all

Several days

More than half the days

Nearly every day

11

Feeling bad about yourself - or that you’re a failure or have let yourself or your family down* This field is required.

Not at all

Several days

More than half the days

Nearly every day

12

Trouble concentrating on things, such as reading the newspaper or watching television* This field is required.

Not at all

Several days

More than half the days

Nearly every day

13

Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual* This field is required.

Not at all

Several days

More than half the days

Nearly every day

14

Thoughts that you would be better off dead or of hurting yourself in some way* This field is required.

Not at all

Several days

More than half the days

Nearly every day

15

Score:

16

Include other comments

17

{patientName},

You scored {typeA} indicating little/no depression. Ketamine infusions are recommended for this score.

Please call (904) 877-1100 for further assistance, thank you.

18

{patientName},

You scored {typeA} indicating a mild level of depression. Ketamine infusions are most likely not warranted until other options have been tried.

Please call (904) 877-1100 for further assistance, thank you.

19

{patientName},

You scored {typeA} indicating a moderate level of depression. Ketamine infusions may be warranted, particularly if standard antidepressants have not worked for you.

Please call (904) 877-1100 for further assistance, or click "next" and enter your phone number if you'd like us to call you

20

{patientName},

You scored {typeA} indicating a moderately severe level of depression. Ketamine infusions may be helpful in relieving your symptoms.

Please call (904) 877-1100 for further assistance, or click "next" and enter your phone number if you'd like us to call you

21

{patientName},

You scored {typeA} indicating a severe level of depression. If you've tried standard antidepressants and they have failed, then ketamine infusions should most certainly be tried.

Please call (904) 877-1100 for further assistance, or click "next" and enter your phone number if you'd like us to call you

22

If you would like us to call you, please enter your phone number.

Please enter a valid phone number.