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512.327.3800
Home
About
Services
Ketamine
Resources
Contact
512.327.3800
Home
About
Services
Ketamine
Resources
Contact
512.327.3800
Home
About
Services
Ketamine
Resources
Contact
512.327.3800
New Patient Form
New Patient Intake
PSYCHIATRIC AND MEDICAL HISTORY FORM
Patient's Name
First
Last
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone - Preferred
Phone - 2nd
Ok to leave confidential message?
Yes
No
Preferred Name
Preferred Pronouns
Gender assigned at birth
Gender Identity
Marital Status
Single
Married / Partner
Divorced
Student Status
Non-student
Full time
Part Time
Age
Date of Birth
MM slash DD slash YYYY
Current Height
feet inches
Current Weight
Please give a brief reason for your visit
Employment
Employer
Occupation
For how long?
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Family Physician
Date
Phone
Fax
Is it OK to contact them?
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Currrent Therapist(s)
Date
Phone
Fax
Is it OK to contact them?
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Past Therapist(s)
Date
Phone
Fax
Is it OK to contact them?
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Phone
Fax
Is it ok to leave a message?
yes
no
Emergency Contact
Name
Phone
Ok to leave message?
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Emergency Contact #2
Name
Phone
Ok to leave message?
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Psychiatric History
List any past psychiatric care and medications prescribed:
Date
Psychiatrist (Name, City, State)
Diagnosis
Medications prescribed
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List any past psychiatric hospitalizations or substance abuse treatment and their dates:
Date
Facility(Name, City, State)
Type of Treatment
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Current or past alcohol use
How Often
How much
Comments
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Current or past drug use
How Often
How much
Comments
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Current or past tobacco or nocotine use
How Often
How much
Comments
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Medical History
Please check if you have been diagnosed with any of the medical conditions listed below:
visual impairment
hearing impairment
Glaucoma
Seizures
Head Injury
Migraine
High Blood Pressure
Heart Disease
High Cholesterol
Asthma
COPD
GERD / Peptic ulcer disease
Irritable bowel or Crohn's
Liver Disease
Diabetes
Kidney Disease
Thyroid Problems
Chronic Pain
Sleep Apnew
Cancer
Other Serious Illness(es)
If yes to any of the above please explain current treatment and status
List all medications, herbs and nutritional supplements you are now taking:
Medication, Herb or Supplement
Dose (MG's, etc)
Prescribed by
Add
Remove
List Any Allergies
Home
About
Services
Ketamine
Resources
Contact
512.327.3800