Ketamine Therapy
 
 
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Questionaire Depression

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What is your name?
What is your email address?
What is your home phone number?
What is your cell phone number?
What is your fax number?
Do you have any current or history of intracranial pathology?
Do you have any history of headaches? What cause? How treated?
Do you have any history of seizures? Treatment?
Do you have high blood pressure? Are you taking medication? Does this control your blood pressure?
Please provide the name, address, and contact phone number of your primary physician:
Please provide the name, address, and contact phone number of your Mental Health Professional:
Who diagnosed you with depression?
How long have you been diagnosed with depression?
What was the initial cause?
How has it changed or progressed?
Are you now, or have you ever been suicidal?
What medications have you used to control it?
How well do the medications control your depression?
What is your age? Gender? Height? Weight?
List your past medical history:
List your past surgical history:
Do you have any allergies to medications? What reaction do you experience?
Please provide a complete list of your current medications, including name of medication, dosage, frequency, and condition used for:
What dates would you prefer to receive treatment?
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