HEALTH HISTORY QUESTIONNAIRE FOR CHRONIC PAIN, MIGRAINES, LONG COVID, & SLEEP DISTURBANCES

Full Name

Date of birth

Screening Age

Screening Weight

Address

Email *

Phone *

Referral Source

Relationship To Patient

Do you have a healthcare power of attorney? (If yes, please provide copy)

Yes

Why are you seeking Ketamine therapy today? (please describe briefly your symptoms (whether pain, sleep disturbance, migraine headaches, or if COVID (date of infection(s), any treatment (Paxlovid, monoclonal antibody infusions, types of symptoms, and vaccine status)

PSYCHOSOCIAL HISTORY:

Are you currently under the care of a mental health specialist (therapist, psychologist, psychiatrist?)

Yes

Name of specialist/specialty:

Frequency of Treatment: (weekly/monthly/yearly)

How long have you been under their care?

Have you been given a formal psychiatric diagnosis? If so, which ones?

Have you ever been hospitalized for depression or anxiety? If so, what is the date of your most recent hospitalization?

Do you have thoughts of suicide?

Yes

Have you ever attempted suicide?

Yes

Describe briefly what other treatments you have tried to alleviate your pain/sleep disturbance/long COVID (meditation, physical therapy, acupuncture, medications, epidural injections)

Have you stopped or modified your work because of these symptoms?

Yes

Describe briefly what other work-up/evaluations you have had for your symptoms? (e.g. neurologist/pain management consultation, sleep study, etc).

Include Combat?

Yes

Military Service?

Yes

Occupation

Marital Status

History of smoking/vaping

Yes

Do you drink alcohol?

Yes

Type/Frequency

Any history of illegal drug use-currently or in the past (please describe more fully noting type, route, and frequency e.g. history of IV heroin use)

Are you currently being treated for any medical conditions? If so, please list below (e.g. cholesterol)

Surgical History: Type of Surgery

Year

Please list the dose and frequency of your current medications:

Allergies?

Yes

Please list what type

Family History: Do you have any family members who have major medical issues or have a history of depression or anxiety disorder?

Father

Mother

Sibling

Please sign here that this information is true and accurate to the best of your knowledge.

Patient Signature *

Clear

Date