Ketamine Therapy
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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?
Have you ever been treated for a psychiatric condition? What was the diagnosis?
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 it 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 pain specialist:
Who diagnosed you with RSD/CRPS, Fibromyalgia, or Lyme Disease?
How long have you had your pain condition?
What was the initial cause?
How has it changed or progressed?
How do you experience it?
What parts of your body are affected?
What medications have you used to control it?
How well do the medications control the pain?
Have you had any interventional treatments such as blocks or injections?
What were the results of these treatments?
Do you have any current incompletely resolved issues or diagnoses that trigger your pain?
Have you ever been told that part of your pain is "narcotic induced hyperalgesia"?
Are you currently physically dependent on narcotics?
Describe your associated symptoms, eg: swelling, skin color or temperature change, reaction to light touch or pressure, sweating or dryness of skin, etc.:
What is your age? Gender? Height? Weight?
List your past medical history:
List your past surgical history:
Do you have any allergies to medications? List reaction:
Please provide a complete list of your current medications including name, dosage, frequency, and condition used for:
How many treatments are you requesting?
What dates do you prefer treatment?
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