Test Form

Name*

First Last

DOB*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Best Contact Method*

Phone
Text
Email

Best Time to Contact*

Student Status

Employment Status

Employer

Employer Address

Primary Care Physician:*

Psychiatrist*

Therapist

Referring 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?*

Yes
No

If someone other than patient is responsible for payment complete this section

Name of responsible party

Relationship

Address

Phone

Employed By

Employer Phone

Employer's Address

Medical Insurance Information

Primary Insurance Name & Address*

Policy Number*

Group Number*

Office visit co-pay

Policyholder*

Policyholder Date of Birth*

Secondary Insurance Name & Address

Policy Number

Group Number

Policyholder

Policyholder Date of Birth

Race

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Primary Language*

Local Pharmacy (Name & Address)

Mail Order Pharmacy (Name & Address)

Acknowledgment of Receipt of Notice of Privacy Practices

I 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*

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 Delivery

Answer 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?*

Ketamine
Spravato
Undecided

Which location would you like to be seen at?*

Moore
Edmond

Are you currently taking an oral antidepressant?*

Yes
No

Please 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?*

Yes
No

If so, please list the medication, start date, and stop date.

Other Medications and Supplements

Please list the name, dose, frequency, reason for taking it, and start date.

Allergies/Reactions

Please list any allergies and reactions.

Medical History*

Do you have any of the following?

Pacemaker?*

Yes
No

Hearing Aids ?*

Yes
No

Implantable Cardiac Defibrillator (ICD)?*

Yes
No

Wearable Cardiac Defibrillator (WCD) ?*

Yes
No

Vagus Nerve Stimulator ?*

Yes
No

Spinal Cord Stimulator ?*

Yes
No

Implantable Medication Pump ?*

Yes
No

Insulin Pump ?*

Yes
No

Piercing ?*

Yes
No

If yes, where, and is it removable?

Plates ?*

Yes
No

If yes, where ?

Screws/Staples ?*

Yes
No

If yes, where ?

Stents ?*

Yes
No

If yes, where ?

Dental Implants ?*

Yes
No

If yes, where ?

Bullet Fragments ?*

Yes
No

If yes, where ?

Shrapnel Fragments ?*

Yes
No

If yes, where ?

Aneurysm clips or coils ?*

Yes
No

If yes, where ?

Cochlear Implants ?*

Yes
No

If yes, where ?

Ocular Implants ?*

Yes
No

If yes, where ?

Deep brain stimulation device ?*

Yes
No

If yes, where ?

Do you have anything not listed above implanted in the head area ?*

Yes
No

If yes, where ?

Have you ever been a machinist, welder, or metal worker ?*

Yes
No

Have you ever had a facial injury from metal and / or metal removed from your eyes ?*

Yes
No

Have you ever had complications from an MRI ?*

Yes
No

Surgeries (list all, include dates):*

Hospitalizations (include dates):*

Pregnancy History (female patients)

Are you or could you be pregnant?

Yes
No

Method of Birth Control:

Date of last menstrual period:

Number of pregnancies:

Number of children:

Last Pap Smear:

Last Mammogram:

Are you currently breastfeeding ?

Yes
No

Are you planning to become pregnant in the next 6 months ?

Yes
No

Reviews of Systems

General Constitutional

Trouble falling asleep ?*

Yes
No

Trouble staying asleep ?*

Yes
No

Pregnant?*

Yes
No

Breastfeeding ?*

Yes
No

Weight Change ?*

Yes
No

Gastrointestinal

Constipation ?*

Yes
No

Diarrhea ?*

Yes
No

Nausea ?*

Yes
No

Vomiting ?*

Yes
No

Endocrine

Cold intolerance ?*

Yes
No

Excessive thirst ?*

Yes
No

Heat intolerance ?*

Yes
No

Musculoskeletal

Joint stiffnes ?*

Yes
No

Painful Joints ?*

Yes
No

Respiratory

Cough ?*

Yes
No

Shortness of breath ?*

Yes
No

Neurologic

Weakness ?*

Yes
No

Dizziness ?*

Yes
No

Headache ?*

Yes
No

Memory loss ?*

Yes
No

Seizures ?*

Yes
No

Tingling / Numbness ?*

Yes
No

Cardiovascular

Chest Pain ?*

Yes
No

Palpitations ?*

Yes
No

Family History

Father

Diabetes
Cancer
Cardiovascular disease
High blood pressure
Mental illness
Obesity
Other

Cancer Type

Other disease

Mother

Diabetes
Cancer
Cardiovascular disease
High blood pressure
Mental illness
Obesity
Other

Cancer Type

Other disease

Siblings

Diabetes
Cancer
Cardiovascular disease
High blood pressure
Mental illness
Obesity
Other

Cancer Type

Other disease

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for:

Are you able to attend treatment appointments twice a week for the first 4 weeks and weekly to monthly after?*

Yes
No

Do you have reliable transportation for ketamine/Spravato (Esketamine) treatment?

Yes
No

At 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 ?*

Yes
No

If yes, list reaction or symptoms

Have you ever been in remission from depression ?*

Yes
No

If so, during what time frame?

Have you participated in:

Inpatient Psychiatric Hospitalization
Psychiatric Partial Hospitalization Program
Intensive Outpatient Psychiatric Program

Dates

Facility(ies)

Reasons

Have you failed treatment with any of the following?

ECT
TMS
Psychotherapy

If you have previously had TMS, which TMS device was used ?

Date

Facility

If you have previously had ECT, what was the outcome ?

Unilateral/Bilateral

Unilateral
Bilateral

Date

Facility

What hand do you use primarily?*

Left
Right
Both

If you are LEFT-handed, are you exclusively left-handed?

Yes
No

What types of psychotherapy have you tried in the past or are you currently in ?

Type other

General/Lifestyle History

Highest educational level or degree

high school diploma/GED
college degree
graduate degree

Are you currently working:

How long have you been in your present position?

What is / was your occupation

Do you exercise regularly:

Yes
No

Number of days per week:

1-2 days
3-4 days
5-6 days
7 days

Type(s):

high impact
low impact
weight training

Do you smoke?

Never
Former smoker
Current smoker

If current smoker, how many cigarettes do you smoke a day?

Are you interested in quitting?

Yes
No

Do you drink alcohol ?

Yes
No

If yes, how often do you drink ?

Do you have a diagnosis of Substance Use Disorder?

Yes
No

Type

Onset

Date of Sobriety

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?*

Yes
No

If yes, are they prescribed?