Medical History - Ketamine Treatment Center

Skip to content

2155 E Conference Dr Ste 101, Tempe, AZ 85284

Ketamine Treatment Center

Primary Navigation Menu

Menu

Home
Ketamine Therapy
Treatment Costs
About Ketamine
Getting Started
About Us
Clinical Research
Contact Us
For Providers
- Email Us
- Referral Form

Please complete the following Confidential Medical Information Form below. If you prefer to download a printable version-CLICK HERE.

Patient Information

Today's Date//

Name *

First

Last

Date of Birth *//

Age

xx

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Emergency Contact Name

Emergency Contact Phone

Primary Care Physician Name

How did you find out about us?

Name of Referring Provider or Patient

Medical Information

Are you under Psychiatric care?

Yes
No

If no, Have you ever been under the Psychiatric care? Who was the provider?

List your current medications* *

*Medication name, dose/amount/number, and prescribing provider's name. If you are not taking medications, please write NONE.

Who prescribes your psychiatric medications?

Is your Prescriber of psychiatric medications aware of your request for Ketamine treatment?

Yes
No

List any discontinued medications (within Past 1 Year)

Medication name, doseages, and prescribing provider's name. If you have not discontinued any medications, please write NONE.

Do you have any allergies?

If Yes, please list them.

Have you had any past surgical procedures

If Yes, please list them.

Have you had any anesthesia problems with you or your family members?

If Yes, please identify relation.

Conditions relating to SELF (Check all that apply):

Depression
PTSD
Schizophrenia
Suicidality
Drug Abuse
Alcohol Abuse
Fibromyalgia
RSD / CRPS
Epilepsy
Glaucoma
High BP
Hepatitis
Renal Failure
Heart Disease

Conditions relating to MOTHER (Check all that apply):

Depression
PTSD
Schizophrenia
Suicidality
Drug Abuse
Alcohol Abuse
Fibromyalgia
RSD / CRPS
Epilepsy
Glaucoma
High BP
Hepatitis
Renal Failure
Heart Disease

Conditions relating to FATHER (Check all that apply):

Depression
PTSD
Schizophrenia
Suicidality
Drug Abuse
Alcohol Abuse
Fibromyalgia
RSD / CRPS
Epilepsy
Glaucoma
High BP
Hepatitis
Renal Failure
Heart Disease

Conditions relating to SIBLINGS (Check all that apply):

Depression
PTSD
Schizophrenia
Suicidality
Drug Abuse
Alcohol Abuse
Fibromyalgia
RSD / CRPS
Epilepsy
Glaucoma
High BP
Hepatitis
Renal Failure
Heart Disease

Medical History (Check all that apply):

Migraines / Headaches
Concussions
COPD / Emphysema
Coronary Artery Disease
Diabetes
Hernia
Blood Disorder
Fibromyalgia
Stroke / TIA
Carotid Artery Disease
Asthma
A-fib
Thyroid Insufficiency
Kidney Disease
Arthritis
Pain Syndromes
Epilepsy
Heart Attack
Bronchitis / Pneumonia
High Cholesterol
GERD / Stomach Ulcer
Chronic Pain
Cancer

Any other health conditions, not mentioned above:

Social History

Marriage Status

Do you have any children?

Yes
No

Number # of people in your household and ages:

For example: 5 - 45, 40, 13, 10, 2

Employer & Occupation:

Level of school:

List hobbies:

Do you exercise regularly?

Yes
No

Are you happy with your weight?

Yes
No

How many meals do you eat per day?

Are you concerned about your alcohol intake?

Yes
No

When was the last time you drank alcohol, what type and how much?

List any non-prescription drug use:

In the last year, have you drank alcohol or used drugs more than you meant to?

Yes
No

Have you wanted/needed to cut down on your drinking or drug use in the last year?

Yes
No

I am not happy with MY (check all that apply):

Self
Partner
Health
Work / School
Life History
Suicide Attempt
Not Applicable

Email

2018-05-03

Founder’s Message

AKTARI was established with sound protocols to meet the highest standards for Ketamine infusions and research, and cultivate ties to the clinical and medical research communities for its scientific endeavors.

Get In Touch

2155 E. Conference Dr. Ste 101
Tempe, AZ 85284

info@arizonaketamine.com

GET STARTED

Copyright © 2023 Arizona Ketamine Treatment & Research Institute, LLC. All Rights Reserved.