Medical History Form Date * MM DD YYYY Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Age * Sex * Height & Weight * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Referring Clinician Name * First Name Last Name Referring Clinician Phone * (###) ### #### Primary Clinician Name * First Name Last Name Primary Clinician Phone * (###) ### #### Therapist's Name First Name Last Name Therapist's Phone (###) ### #### Principal Psychiatric Diagnosis * Other Psychiatric Diagnoses Current Medications & Doses * Medications you have tried in the past but have since discontinued usage Do you currently suffer from suicidal thoughts? * Yes No If so, how often? Allergies & Adverse Reactions? Medical Problems * Surgical History * Any history of problems with anesthesia for you or anyone in your family? * Yes No If so, please describe: Emergency Room Visits? * Please describe any emergency room admissions in the past 3 months. History of difficult IV stick/blood draw? * Yes No History of Substance Use For each substance listed, please describe how much you use, how often you use it, when you used it last, and for how many years you have been using it? Tobacco * Alcohol * Marijuana * Cocaine * Heroin * Other Review of Systems Please check off the various symptoms you are experiencing for each bodily system. General * Weight Loss/Gain Fatigue Fever or Chills Weakness Trouble Sleeping None Skin * Rashes Lumps Itching Dryness Color Changes Hair & Nail Changes None Head * Headache Head Injury Neck Pain None Ears * Decreased Hearing Ringing in Ears Earache Drainage None Eyes * Vision Loss/Changes Glasses/Contacts Pain Redness Blurry or Double Vision Flashing Lights Specks Glaucoma Cataracts None Nose * Stuffiness Discharge Itching Hay Fever Nosebleeds Sinus Pain None Throat * Bleeding Dentures Sore Tongue Dry Mouth Sore Throat Hoarseness Thrush Non-Healing Sores None Neck * Lumps Swollen Glands Pain Stiffness None Breasts * Breastfeeding None Respiratory * Cough Sputum Coughing Up Blood Shortness of Breath Wheezing Painful Breathing None Cardiovascular * Chest Pain/Discomfort Tightness Palpitations Shortness of Breath with Activity Difficulty Breathing Lying Down Swelling Sudden Awakening from Sleep with Shortness of Breath None Gastrointestinal * Swallowing Difficulties Heartburn Change in Appetite Nausea Change in Bowel Habits Rectal Bleeding Constipation Diarrhea Yellow Eyes/Skin None Urinary * Frequency Urgency Burning or Pain Blood in Urine Incontinence Change in Urinary Strength None Vascular * Calf Pain with Walking Leg Cramping None Musculoskeletal * Muscle/Joint Pain Stiffness Back Pain Redness of Joints Swelling of Joints Trauma None Neurologic * Dizziness Fainting Seizures Weakness Numbness Tingling Tremor Stroke None Hematologic * Ease of Bruising Ease of Bleeding None Endocrine * Heat or Cold Intolerance Sweating Frequent Urination Thirst Change in Appetite None Psychiatric * Anxiety PTSD Depression Memory Loss Mania Bipolar Disorder Postpartum Depression Major Depressive Disorder None Thank you! Privacy Policy Payment & Cancellation Policy Medical History Form Consent To Electronic Communications Informed Consent to Ketamine Treatments Acknowledgement of Ongoing Care
