Lattice Infusion Therapy

Health questionnaire for ketamine treatment

Personal Information:


Full Name:
Date of Birth:
Contact Information:

Emergency Contact Information:


Name:
Relationship:
Phone Number:

Mental Health History:


Current Mental Health Diagnoses

Date(s) of Diagnoses:
Diagnoses:

Current Prescriptions (for mental health):

Medication Name(s):
Date Prescribed:

Current Prescriptions (for mental health):

Medication Name(s):

Mental Health Provider Details

Provider Who Made the Diagnosis:
Current Primary Mental Health Provider:
Provider’s Contact Information:

General Health Information


Other Current Medical Conditions (Please be specific):

Other Current Medication(s)

Medication(s):
Purpose:

Allergies and Sensitivities:

Specific Allergies to Medication(s):
Other Sensitivities:

Health Habits

Tobacco Use:
Alcohol Use:
Use of Recreational or Non-prescription Drugs:

Ketamine Therapy History


Prior Ketamine Infusions

Number of Infusions:
Opinion of Experience:

Treatment Goals and Expectations

Goals for Ketamine Therapy:
Expectations from Lattice Infusion Therapy:

Privacy and Confidentiality

Consent and Confirmation

Signature:
Date:
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