Test Form New Patient Form Name* First Last DOB* MM slash DD slash YYYY 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 sectionName of responsible party Relationship Address PhoneEmployed By Employer PhoneEmployer's Address Medical Insurance InformationPrimary Insurance Name & Address* Policy Number* Group Number* Office visit co-pay Policyholder* Policyholder Date of Birth* MM slash DD slash YYYY Secondary Insurance Name & Address Policy Number Group Number Policyholder Policyholder Date of Birth Race Asian Native Hawaiian or the other Pacific Islander Black or African American White Other 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 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* 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 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 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?* 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 SystemsGeneral ConstitutionalTrouble falling asleep ?* Yes No Trouble staying asleep ?* Yes No Pregnant?* Yes No Breastfeeding ?* Yes No Weight Change ?* Yes No GastrointestinalConstipation ?* Yes No Diarrhea ?* Yes No Nausea ?* Yes No Vomiting ?* Yes No EndocrineCold intolerance ?* Yes No Excessive thirst ?* Yes No Heat intolerance ?* Yes No MusculoskeletalJoint stiffnes ?* Yes No Painful Joints ?* Yes No RespiratoryCough ?* Yes No Shortness of breath ?* Yes No NeurologicWeakness ?* Yes No Dizziness ?* Yes No Headache ?* Yes No Memory loss ?* Yes No Seizures ?* Yes No Tingling / Numbness ?* Yes No CardiovascularChest Pain ?* Yes No Palpitations ?* Yes No Family HistoryFather 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 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?* 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 ? 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 other General/Lifestyle HistoryHighest educational level or degree high school diploma/GED college degree graduate degree Are you currently working: working not working by choice unemployed disabled retired How long have you been in your present position? 1-3 months 6-12 months 1-3 years 6-10 years 10+ years 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 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?* Yes No If yes, are they prescribed? If yes, provide frequency and date of last use. Ketamine?* Yes No If yes, is it prescribed? If yes, provide frequency and date of last use. Cocaine?* Yes No If yes, provide frequency and date of last use. Alcohol?* Yes No If yes, provide frequency and date of last use. Tobacco* Yes No If yes, provide frequency and date of last use. Vape?* Yes No If yes, provide frequency and date of last use. Lysergic Acid Diethylamide (LSD)?* Yes No If yes, provide frequency and date of last use. Psilocybin (magic mushrooms)* Yes No If yes, provide frequency and date of last use. Have you used drugs other than those required for medical reasons?* Yes No Have you abused prescription drugs?* Yes No If yes, which ones and for how long? Are you always able to stop drinking/using drugs when you want to?* Yes No Have you ever been in trouble because of alcohol/drug abuse?* Yes No Have you ever experienced withdrawal symptoms as a result of heavy alcohol/drug intake?* Yes No Have you ever been treated for alcohol or drug abuse?* Yes No Do you think you may have a problem with alcohol or drug use ?* Yes No Social HistoryDo you have a good support system?* Yes No Are you married ?* Yes No How many years? Are you: Divorced Single Widowed How many years? If not married, are you currently in a relationship ? Yes No How long? Do you have children?* Yes No If yes, list ages and gender:Have you ever been arrested ? Yes No Do you have any pending legal problems ? Yes No Have you traveled outside the US ? Yes No Do you have a history of being abused emotionally, sexually, physically or by neglect ? Yes No Do you belong to a particular religion or spiritual group ? Yes No If yes, do you find your involvement makes things more difficult or stressful? Yes No If yes, do you find your involvement is helpful ? Yes No Bipolar 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?* Yes No If yes, when was the last time you were manic? ________________ Do you have thoughts others think are bizarre or out of touch with reality?* Yes No Do you ever hear voices or see things that aren’t there?* Yes No Do you ever feel paranoid or feel like others are out to get you?* Yes No Do you feel like others are sending you messages or controlling your mind or thoughts?* Yes No Mark 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 Others Antipsychotics / Mood Stabilizers Ability (aripiprazole) Clozaril (clozapine) Geodon (ziprasidone) Latuda (lurasidone) Risperdal (risperidone) Saphris (asenapine) Seroquel (quetiapine) Zyprexa (olanzapine) Others List Others Sedative / Hypnotics Ambien (zolpidem) Desyrel (trazodone) Lunesta (eszopiclone) Restoril (temazepam) Rozerem (ramelteon) Sonata (zaleplon) Others List Others Anxiety medications Ativan (lorazepam) Buspar (buspirone) Klonopin (clonazepam) Tranxene (clorazepate) Valium (diazepam) Xanax (alprazolam) Xanax XR Others List Others ADHD medications Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Vyvanse (lisadexamfetamine) Others List Others Past 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) 25mg 50mg 75mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Celexa (citalopram) 10mg 20mg 40mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Cymbalta (duloxetine) 20mg 30mg 40mg 60mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Effexor (venlafaxine) 37.5mg 75mg 150mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Elavil (amitriptyline) 10mg 25mg 50mg 75mg 100mg 150mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Fetzima (levomilnacipran) 20mg 40mg 80mg 120mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Lexapro (escitalopram) 5mg 10mg 20mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Luvox (fluvoxamine) 25mg 50mg 100mg 150mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Pamelor (nortriptyline) 10mg 25mg 50mg 75mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Paxil (paroxetine) 10mg 20mg 30mg 40mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Pristiq (desvenlafaxine) 25mg 50mg 100mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Prozac (fluoxetine) 10mg 20mg 40mg 60mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Remeron (mirtazapine) 7.5mg 15mg 30mg 45mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Topamax (topiramate) 25mg 50mg 100mg 200mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Desyrel (trazadone) 25mg 50mg 100mg 150mg 300mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Trintellix (vortioxetine) 5mg 10mg 20mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Viibryd (vilazodone) 10mg 20mg 40mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Wellbutrin (bupropion) 75mg 100mg 150mg 200mg 300mg 450mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Zoloft (sertraline) 25mg 50mg 100mg Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Other Start Date MM slash DD slash YYYY Stop Date MM slash DD slash YYYY Reason for Discontinuation Beck 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 to 11. 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 all 1 Several days 2 More than half the days 3 Nearly every day 2. Feeling down, depressed, or hopeless* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 3. Trouble falling or staying asleep, or sleeping too much* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 4. Feeling tired or having little energy* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 5. Poor appetite or overeating* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day 8. 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 all 1 Several days 2 More than half the days 3 Nearly every day 9. Thoughts that you would be better off dead, or of hurting yourself.* 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day PHQ - 9 TotalCAPTCHANameThis field is for validation purposes and should be left unchanged.
