Test Form New Patient Form Name* First Last DOB* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Best Contact Method*PhoneTextEmailBest Time to Contact*Student StatusEmployment StatusEmployerEmployer AddressPrimary Care Physician:*Psychiatrist*TherapistReferring Physician*Emergency Contact*Relationship*Emergency Contact Address*Emergency Contact Phone*How did you hear about Mind Mood Pain?Would you like us to update your mental health provider after treatment?*YesNoIf someone other than patient is responsible for payment complete this sectionName of responsible partyRelationshipAddressPhoneEmployed ByEmployer PhoneEmployer's AddressMedical Insurance InformationPrimary Insurance Name & Address*Policy Number*Group Number*Office visit co-payPolicyholder*Policyholder Date of Birth* Date Format: MM slash DD slash YYYY Secondary Insurance Name & AddressPolicy NumberGroup NumberPolicyholderPolicyholder Date of BirthRaceAsianNative Hawaiian or the other Pacific IslanderBlack or African AmericanWhiteOtherEthnicityHispanic or LatinoNot Hispanic or LatinoPrimary Language*Local Pharmacy (Name & Address)Mail Order Pharmacy (Name & Address)Acknowledgment of Receipt of Notice of Privacy PracticesI understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. • Obtain payment from third-party payers. • Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Private Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.* I understand Name* First Last Date* Date Format: MM slash DD slash YYYY What have you been diagnosed with? Major Depressive Disorder Suicidal Ideation Bipolar Depression Premenstrual Dysphoric Disorder Postpartum Depression Generalized Anxiety Disorder Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Other Please write the approximate date of each diagnosis.Date of DeliveryAnswer for Postpartum Depression*If you are having thoughts of harming yourself, please call 911 or go to the nearest emergency immediately.Which treatment are you interested in?*KetamineSpravatoUndecidedWhich location would you like to be seen at?*MooreEdmondAre you currently taking an oral antidepressant?*YesNoPlease list the medication, dose, frequency, and when you began this medication.Are you currently taking, or have you ever taken any medication for a seizure disorder?*YesNoIf so, please list the medication, start date, and stop date.Other Medications and SupplementsPlease list the name, dose, frequency, reason for taking it, and start date. Allergies/ReactionsPlease list any allergies and reactions. Medical History* Abnormal MRI Eating Disorder Interstitial Cystitis Aneurysm Restless Leg Syndrome Anemia Epilepsy Raised intracranial pressure Bipolar Mania Alcohol Dependence Asthma Chronic Fatigue Raised intraocular pressure Nausea Psychosis Autoimmune Disorder Fibromyalgia Kidney Disease Dizziness Arteriovenous Malformation Blood Clots Head trauma | concussions Liver Disease Motion Sickness Brain Tumor(s) Bladder Issues Headaches Migraine Eye Pain Schizophrenia Cancer Heart Disease Seizure Toothache Active Substance Abuse Chronic Pain High Blood Pressure Stomach problems Hearing Loss Diabetes Mellitus High cholesterol Stroke Ringing in Ears Drug Abuse Hyperthyroid Thyroid Disease Claustrophobia Do you have any of the following?Pacemaker?*YesNoHearing Aids ?*YesNoImplantable Cardiac Defibrillator (ICD)?*YesNoWearable Cardiac Defibrillator (WCD) ?*YesNoVagus Nerve Stimulator ?*YesNoSpinal Cord Stimulator ?*YesNoImplantable Medication Pump ?*YesNoInsulin Pump ?*YesNoPiercing ?*YesNoIf yes, where, and is it removable?Plates ?*YesNoIf yes, where ?Screws/Staples ?*YesNoIf yes, where ?Stents ?*YesNoIf yes, where ?Dental Implants ?*YesNoIf yes, where ?Bullet Fragments ?*YesNoIf yes, where ?Shrapnel Fragments ?*YesNoIf yes, where ?Aneurysm clips or coils ?*YesNoIf yes, where ?Cochlear Implants ?*YesNoIf yes, where ?Ocular Implants ?*YesNoIf yes, where ?Deep brain stimulation device ?*YesNoIf yes, where ?Do you have anything not listed above implanted in the head area ?*YesNoIf yes, where ?Have you ever been a machinist, welder, or metal worker ?*YesNoHave you ever had a facial injury from metal and / or metal removed from your eyes ?*YesNoHave you ever had complications from an MRI ?*YesNoSurgeries (list all, include dates):*Hospitalizations (include dates):*Pregnancy History (female patients)Are you or could you be pregnant?YesNoMethod of Birth Control:Date of last menstrual period:Number of pregnancies:Number of children:Last Pap Smear:Last Mammogram:Are you currently breastfeeding ?YesNoAre you planning to become pregnant in the next 6 months ?YesNoReviews of SystemsGeneral ConstitutionalTrouble falling asleep ?*YesNoTrouble staying asleep ?*YesNoPregnant?*YesNoBreastfeeding ?*YesNoWeight Change ?*YesNoGastrointestinalConstipation ?*YesNoDiarrhea ?*YesNoNausea ?*YesNoVomiting ?*YesNoEndocrineCold intolerance ?*YesNoExcessive thirst ?*YesNoHeat intolerance ?*YesNoMusculoskeletalJoint stiffnes ?*YesNoPainful Joints ?*YesNoRespiratoryCough ?*YesNoShortness of breath ?*YesNoNeurologicWeakness ?*YesNoDizziness ?*YesNoHeadache ?*YesNoMemory loss ?*YesNoSeizures ?*YesNoTingling / Numbness ?*YesNoCardiovascularChest Pain ?*YesNoPalpitations ?*YesNoFamily HistoryFather Diabetes Cancer Cardiovascular disease High blood pressure Mental illness Obesity Other Cancer TypeOther diseaseMother Diabetes Cancer Cardiovascular disease High blood pressure Mental illness Obesity Other Cancer TypeOther diseaseSiblings Diabetes Cancer Cardiovascular disease High blood pressure Mental illness Obesity Other Cancer TypeOther diseaseFamily Psychiatric HistoryHas anyone in your family been diagnosed with or treated for: Alcohol Abuse Depression Post-traumatic stress Anger Eating disorder Substance Abuse Anxiety Insomnia Suicide attempts Bipolar disorder Personality disorders Violence Are you able to attend treatment appointments twice a week for the first 4 weeks and weekly to monthly after?*YesNoDo you have reliable transportation for ketamine/Spravato (Esketamine) treatment?YesNoAt what age were you initially diagnosed with depression (estimate):Have you experienced a poor response to oral antidepressants in the past?IF yes, list reaction or symptoms:Have you experienced intolerable side effects to antidepressants in the past?Have you ever had a reaction to Ketamine or Esketamine ?*YesNoIf yes, list reaction or symptomsHave you ever been in remission from depression ?*YesNoIf so, during what time frame?Have you participated in: Inpatient Psychiatric Hospitalization Psychiatric Partial Hospitalization Program Intensive Outpatient Psychiatric Program DatesFacility(ies)ReasonsHave you failed treatment with any of the following? ECT TMS Psychotherapy If you have previously had TMS, which TMS device was used ?DateFacilityIf you have previously had ECT, what was the outcome ?Unilateral/Bilateral Unilateral Bilateral DateFacilityWhat hand do you use primarily?*LeftRightBothIf you are LEFT-handed, are you exclusively left-handed?YesNoWhat types of psychotherapy have you tried in the past or are you currently in ? Talk Therapy Cognitive Behavioral Therapy Client-Centered Therapy Existential Therapy Extended Visits with Psychiatrist Group Therapy Dialectical Behavioral Therapy Interpersonal Therapy Mindfulness Therapy Psychoanalytic or Psychodynamic Therapy Other Type otherGeneral/Lifestyle HistoryHighest educational level or degreehigh school diploma/GEDcollege degreegraduate degreeAre you currently working:workingnot working by choiceunemployeddisabledretiredHow long have you been in your present position?1-3 months6-12 months1-3 years6-10 years10+ yearsWhat is / was your occupationDo you exercise regularly:YesNoNumber of days per week:1-2 days3-4 days5-6 days7 daysType(s):high impactlow impactweight trainingDo you smoke?NeverFormer smokerCurrent smokerIf current smoker, how many cigarettes do you smoke a day?Are you interested in quitting?YesNoDo you drink alcohol ?YesNoIf yes, how often do you drink ?Do you have a diagnosis of Substance Use Disorder?YesNoTypeOnsetDate of Sobriety Date Format: MM slash DD slash YYYY Current substance abuse or dependence can complicate treatment with Spravato (Esketamine) and ketamine. A history of substance abuse increases the risk of abusing ketamine recreationally. The following questions help us determine if treatment is appropriate for you at this time.Have you used any of the following substances in the last 6 months? If yes, please list how often you use them and the last date of use. (Please indicate if the substance is medically prescribed)Opiates?*YesNoIf yes, are they prescribed?If yes, provide frequency and date of last use.Ketamine?*YesNoIf yes, is it prescribed?If yes, provide frequency and date of last use.Cocaine?*YesNoIf yes, provide frequency and date of last use.Alcohol?*YesNoIf yes, provide frequency and date of last use.Tobacco*YesNoIf yes, provide frequency and date of last use.Vape?*YesNoIf yes, provide frequency and date of last use.Lysergic Acid Diethylamide (LSD)?*YesNoIf yes, provide frequency and date of last use.Psilocybin (magic mushrooms)*YesNoIf yes, provide frequency and date of last use.Have you used drugs other than those required for medical reasons?*YesNoHave you abused prescription drugs?*YesNoIf yes, which ones and for how long?Are you always able to stop drinking/using drugs when you want to?*YesNoHave you ever been in trouble because of alcohol/drug abuse?*YesNoHave you ever experienced withdrawal symptoms as a result of heavy alcohol/drug intake?*YesNoHave you ever been treated for alcohol or drug abuse?*YesNoDo you think you may have a problem with alcohol or drug use ?*YesNoSocial HistoryDo you have a good support system?*YesNoAre you married ?*YesNoHow many years?Are you:DivorcedSingleWidowedHow many years?If not married, are you currently in a relationship ?YesNoHow long?Do you have children?*YesNoIf yes, list ages and gender:Have you ever been arrested ?YesNoDo you have any pending legal problems ?YesNoHave you traveled outside the US ?YesNoDo you have a history of being abused emotionally, sexually, physically or by neglect ?YesNoDo you belong to a particular religion or spiritual group ?YesNoIf yes, do you find your involvement makes things more difficult or stressful?YesNoIf yes, do you find your involvement is helpful ?YesNoBipolar Mania and Psychosis are contraindications to treatment with Spravato (Esketamine) and ketamine. The following questions assess your recent mental status to ensure that you are not currently experiencing a manic or hypomanic episode or an episode of psychosis. Answer yes or no to the following questions.Have you ever been diagnosed with Bipolar mania?*YesNoIf yes, when was the last time you were manic? ________________Do you have thoughts others think are bizarre or out of touch with reality?*YesNoDo you ever hear voices or see things that aren’t there?*YesNoDo you ever feel paranoid or feel like others are out to get you?*YesNoDo you feel like others are sending you messages or controlling your mind or thoughts?*YesNoMark symptoms you’ve experienced in the past 2 weeks:* I feel happier or more cheerful than usual I feel more self-confident than usual I need less sleep than usual I frequently talk more than usual I have frequently been more active than usual Past Psychiatric Medications: Have you ever taken any of the following medications?Mood Stabilizers Tegretol (carbamazepine) Depakote (valproate) Lamictal (lamotrigine) Lithium Trileptal (oxcarbazepine) Others List OthersAntipsychotics / Mood Stabilizers Ability (aripiprazole) Clozaril (clozapine) Geodon (ziprasidone) Latuda (lurasidone) Risperdal (risperidone) Saphris (asenapine) Seroquel (quetiapine) Zyprexa (olanzapine) Others List OthersSedative / Hypnotics Ambien (zolpidem) Desyrel (trazodone) Lunesta (eszopiclone) Restoril (temazepam) Rozerem (ramelteon) Sonata (zaleplon) Others List OthersAnxiety medications Ativan (lorazepam) Buspar (buspirone) Klonopin (clonazepam) Tranxene (clorazepate) Valium (diazepam) Xanax (alprazolam) Xanax XR Others List OthersADHD medications Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Vyvanse (lisadexamfetamine) Others List OthersPast Psychiatric Medications Continued: Have you ever taken any of the following medications? This portion needs to be filled out to the best of your knowledge in order to submit for approval. Estimated dates can be given.Anafranil (clomipramine)25mg50mg75mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationCelexa (citalopram)10mg20mg40mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationCymbalta (duloxetine)20mg30mg40mg60mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationEffexor (venlafaxine)37.5mg75mg150mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Elavil (amitriptyline)10mg25mg50mg75mg100mg150mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationFetzima (levomilnacipran)20mg40mg80mg120mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationLexapro (escitalopram)5mg10mg20mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationLuvox (fluvoxamine)25mg50mg100mg150mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationPamelor (nortriptyline)10mg25mg50mg75mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationPaxil (paroxetine)10mg20mg30mg40mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationPristiq (desvenlafaxine)25mg50mg100mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationProzac (fluoxetine)10mg20mg40mg60mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationRemeron (mirtazapine)7.5mg15mg30mg45mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationTopamax (topiramate)25mg50mg100mg200mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationDesyrel (trazadone)25mg50mg100mg150mg300mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationTrintellix (vortioxetine)5mg10mg20mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationViibryd (vilazodone)10mg20mg40mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationWellbutrin (bupropion)75mg100mg150mg200mg300mg450mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationZoloft (sertraline)25mg50mg100mgStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationOtherStart Date Date Format: MM slash DD slash YYYY Stop Date Date Format: MM slash DD slash YYYY Reason for DiscontinuationBeck Depression Questionnaire1. Choose what applies.*0 I do not feel sad.1 I feel sad.2 I am sad all the time and I can’t snap out of it.3 I am so sad and unhappy that I can’t stand it.2. Choose what applies.*0 I am not particularly discouraged about the future.1 I feel discouraged about the future.2 I feel I have nothing to look forward to.3 I feel the future is hopeless and that things cannot improve.3. Choose what applies.*0 I do not feel like a failure.1 I feel I have failed more than the average person.2 As I look back on my life, all I can see is a lot of failures.3 I feel I am a complete failure as a person.4. Choose what applies.*0 I get as much satisfaction out of things as I used to.1 I don’t enjoy things the way I used to.2 I don’t get real satisfaction out of anything anymore.3 I am dissatisfied or bored with everything.5. Choose what applies.*0 I don’t feel particularly guilty.1 I feel guilty a good part of the time.2 I feel quite guilty most of the time.3 I feel guilty all of the time.6. Choose what applies.*0 I don’t feel I am being punished.1 I feel I may be punished.2 I expect to be punished.3 I feel I am being punished.7. Choose what applies.*0 I don’t feel disappointed in myself.1 I am disappointed in myself.2 I am disgusted with myself.3 I hate myself.8. Choose what applies.*0 I don’t feel I am any worse than anybody else.1 I am critical of myself for my weaknesses or mistakes.2 I blame myself all the time for my faults.3 I blame myself for everything bad that happens.9. Choose what applies.*0 I don’t have any thoughts of killing myself.1 I have thoughts of killing myself, but I would not carry them out.2 I would like to kill myself.3 I would kill myself if I had the chance.10. Choose what applies.*0 I don’t cry any more than usual.1 I cry more now than I used to.2 I cry all the time now.3 I used to be able to cry, but now I can’t cry even though I want to11. Choose what applies.*0 I am no more irritated by things than I ever was.1 I am slightly more irritated now than usual.2 I am quite annoyed or irritated a good deal of the time.3 I feel irritated all the time.12. Choose what applies.*0 I have not lost interest in other people.1 I am less interested in other people than I used to be.2 I have lost most of my interest in other people.3 I have lost all interest in other people.13. Choose what applies.*0 I make decisions about as well as I ever could.1 I put off making decisions more than I used to.2 I have greater difficulty in making decisions more than I used to.3 I can’t make decisions at all anymore.14. Choose what applies.*0 I don’t feel that I look any worse than I used to.1 I am worried that I am looking old or unattractive.2 I feel there are permanent changes in my appearance that make me look unattractive.3 I believe that I look ugly.15. Choose what applies.*0 I can work about as well as before.1 It takes an extra effort to get started at doing something.2 I have to push myself very hard to do anything.3 I can’t do any work at all.16. Choose what applies.*0 I can sleep as well as usual.1 I don’t sleep as well as I used to.2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.3 I wake up several hours earlier than I used to and cannot get back to sleep.17. Choose what applies.*0 I don’t get more tired than usual.1 I get tired more easily than I used to.2 I get tired from doing almost anything.3 I am too tired to do anything.18. Choose what applies.*0 My appetite is no worse than usual.1 My appetite is not as good as it used to be.2 My appetite is much worse now.3 I have no appetite at all anymore.19. Choose what applies.*0 I haven’t lost much weight, if any, lately.1 I have lost more than five pounds.2 I have lost more than ten pounds.3 I have lost more than fifteen pounds.20. Choose what applies.*0 I am no more worried about my health than usual.1 I am worried about my physical problems like aches, pains, upset stomach, or constipation.2 I am very worried about my physical problems and it’s hard to think of anything else.3 I am so worried about my physical problems that I cannot think of anything else.21. Choose what applies.*0 I have not noticed any recent change in my interest in sex.1 I am less interested in sex than I used to be.2 I have almost no interest in sex.3 I have lost interest in sex completely.Beck Depression TotalPatient Health Questionnaire 9Over the last 2 weeks, how often have you been bothered by any of the following problems?1. Little interest or pleasure in doing things*0 Not at all1 Several days2 More than half the days3 Nearly every day2. Feeling down, depressed, or hopeless*0 Not at all1 Several days2 More than half the days3 Nearly every day3. Trouble falling or staying asleep, or sleeping too much*0 Not at all1 Several days2 More than half the days3 Nearly every day4. Feeling tired or having little energy*0 Not at all1 Several days2 More than half the days3 Nearly every day5. Poor appetite or overeating*0 Not at all1 Several days2 More than half the days3 Nearly every day6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down*0 Not at all1 Several days2 More than half the days3 Nearly every day7. Trouble concentrating on things, such as reading the newspaper or watching television*0 Not at all1 Several days2 More than half the days3 Nearly every day8. Moving or speaking so slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual*0 Not at all1 Several days2 More than half the days3 Nearly every day9. Thoughts that you would be better off dead, or of hurting yourself.*0 Not at all1 Several days2 More than half the days3 Nearly every dayPHQ - 9 TotalCAPTCHAEmailThis field is for validation purposes and should be left unchanged.