Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What is the primary reason you receive Ketamine Therapy? *

Select most appropriate

Mental Health

Pain

Both (Primarily Mental Health)

Both (Primarily Pain)

What is your preference method of administration for home ketamine therapy? *

Troche

Rapidly Dissolving Tablet

Suppository

Nasal Spray

Do you currently take any of the following? *

Select all that apply

Opioids

Benzodiazepines

Marijuana

Stimulants

LSD

Cocaine

Methamphetamines

Ecstasy

Psilocybin

None

Have you ever suffered from substance dependence or abuse?

Yes

No

Are you actively seeing a mental health provider or therapist? *

Within the last 2 months

Yes

No

Are you actively seeing a pain management provider? *

Within the last 6 months

Yes

No

Have you received an IV infusion of Ketamine within the last 6 months? *

Yes

No

Have you received Spravato treatment within the last 2 months? *

Yes

No

Please describe your pain *

Select all that apply

None

Sharp

Stabbing

Throbbing

Burning

Aching

Numbness

Tingling

Other

1. Over the last 2 weeks, how often have you been bothered by the following problems? Little interest or pleasure in doing things *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

2. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling down, depressed or hopeless *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

3. Over the last 2 weeks, how often have you been bothered by the following problems? Trouble falling asleep, staying asleep, or sleeping too much *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

4. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling tired or having little energy *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

5. Over the last 2 weeks, how often have you been bothered by the following problems? Poor appetite or overeating *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

6. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling bad about yourself - or that you’re a failure or have let yourself or your family down *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

7. Over the last 2 weeks, how often have you been bothered by the following problems? Trouble concentrating on things, such as reading the newspaper or watching television *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

8. Over the last 2 weeks, how often have you been bothered by the following problems? 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 *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

9. Over the last 2 weeks, how often have you been bothered by the following problems? Thoughts that you would be better off dead or of hurting yourself in some way *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

1. Over the last two weeks, how often have you been bothered by the following problems? Feeling nervous, anxious, or on edge *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

2. Over the last two weeks, how often have you been bothered by the following problems? Not being able to stop or control worrying *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

3. Over the last two weeks, how often have you been bothered by the following problems? Worrying too much about different things *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

4. Over the last two weeks, how often have you been bothered by the following problems? Trouble relaxing *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

5. Over the last two weeks, how often have you been bothered by the following problems? Being so restless that it is hard to sit still *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

6. Over the last two weeks, how often have you been bothered by the following problems? Becoming easily annoyed or irritable *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

7. Over the last two weeks, how often have you been bothered by the following problems? Feeling afraid, as if something awful might happen *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)