Intake Form

Intake Form

Before coming in for a consultation or treatment, save some time and stress by completing this necessary intake form.

*Be advised this information remains confidential within the confines of our medical office. The information you provide will not be sold or released to third parties.

Name:

Middle Name:

Last Name:

Date of Birth:

Age:

Home Phone:

Cell Phone:

Social Security Number:

Drivers License #, State:

E-mail:

Mailing Address:

Mailing Address Line 2

City:

State/Province:

Postal/Zip Code:

Psychiatrist and/or Pain Physician Name:

Psychiatrist and/or Pain Physician Address:

City:

State/Province:

Postal/Zip Code:

Therapist Name:

Therapist Street Address:

Therapist Street Address Line 2

City:

State / Province:

Postal / Zip Code :

Have you ever tried electrocompulsive therapy (ECT) and/or transcranial magnetic stimulation (TMS)? If so, please provide treatment details (i.e. location, date)

How did you hear about us?

What is your occupation and who is your employer?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number:

Relationship to Patient

What is your weight?

What is your height:

List of medical conditions you have

List of CURRENT medications you take and dosages (e.g., Zoloft, 20 mg)

List of all things you are allergic to and reaction. Example: penicillin (rash)

List all psychiatric and pain medications including dosage tried

List type and date of all surgeries you have had. Example: knee surgery (2009)

Does anyone in your immediate family have major medical problems? If so, list them:

Any problems with Anesthesia (i.e., nausea, delayed emergence, airway issues)?

Have you or any of your family members had any problems with anesthesia in the past? If so, what happened?

Do you have any active neurological conditions (stroke, concussion, seizures)?

Do you have any active cardiac conditions (high blood pressure, heart attack, abnormal rhythm)?

Do you have any active gastro-intestinal conditions (hepatitis, ulcerative colitis)?

Do you have any active kidney problems (renal failure, dialysis)?

Do you have any active pulmonary conditions (asthma, COPD, tobacco use)?

Have/do you use any recreational or illegal drugs?

How much alcohol do you drink? Example: 2 glasses of wine per day

Are you currently pregnant or breast feeding or planning on becoming pregnant in the near future?

By checking the following box, I declare that the information I have provided within this form is true.

I declare that the information I have provided within this form is true.

Intake Form

Before coming in for a consultation or treatment, save some time and stress by completing this necessary intake form.

Intake Form

520 Franklin AveGarden City, NY 11530Suite 103(516) 280-3842contact@ketamine-wellness.com

520 Franklin Ave
Garden City, NY 11530
Suite 103
(516) 280-3842
contact@ketamine-wellness.com