KAP Medical Screening Questionnaire

1

Name

First Name

Last Name

2

Email

example@example.com

3

Do you have a Psychiatrist?

Yes

No

4

Psychiatrist Name

5

Psychiatrist Contact Info

6

Psychiatric Diagnosis

7

1. Any history of sensitivities/allergies to eskatamine or ketamine?

Yes

No

8

2. Have you ever been diagnosed with high blood pressure?

Yes

No

9

3. If so, is your blood pressure currently managed with medication or other therapies?

Yes

No

10

4. Have you ever been diagnosed with a thyroid disorder?

Yes

No

11

5. Any history of aneurysmal vascular disease(including thoracic and/or abdominal aorta, intracranial and peripheral arterial vessels or AV malformation)?

Yes

No

12

6. Any history of intracerebral hemorrhage?

Yes

No

13

7. Any history of hepatic impairment?

Yes

No

14

8. Is there any chance you may be pregnant or are planning to become pregnant?

Yes

No

Skip/NA

15

9. Are you breastfeeding?

Yes

No

Skip/NA

16

10. Do You Menstruate?

Yes

No/Skip

Not Anymore

Other

17

10a. When was your last normal period?

Date

18

1. Have you ever been diagnosed with bipolar disorder or have experienced a manic or hypomanic episode in the past?

Yes

No

19