Ketamine Form | R. Joe Ybarra MD - Private Practice & Wellness Clinic

Name:

Date of Birth:

Age:

Gender:

Phone:

Email:

How did you hear about us MedSpa SPI?

Referring Provider:

Phone:

Primary Care Provider:

Phone:

Mental Health Providers:

Phone:

Allergies:

No Allergies

List any allergies to medication/food/supplements or check "No Allergies" above.

Past Medical History:

Have you experienced any of these conditions?

Check all that apply.
If so, tell us if it is a current or past condition.
Provide date of onset or how long you have been experiencing the condition.

Metabolic/Endocrine

Hypothyroid (underactive):

Hyperthyroidism (overactive thyroid):

Respiratory

Shortness of Breath:

Obstructive Sleep Apnea:

Pulmonary Hypertension:

Other Lung Disorders:

GU/GI

Cardiovascular

High Blood Presure Controlled/Uncontrolled:

Abnormal Heart Rhythm:

Pain

Infectious

Hematology/Oncology

Other

Other Recreational Drugs and Last Use:

History of Violent Behavior:

Past Surgical History:

No Surgical History

List any surgeries you have had and the date of the surgery. If you haven't had any surgeries check the box above.

Current Medications/Supplements:

No Medication

List the Name, Dose and Reason for use for all Current Medications and Supplements you are taking.

I am currently compliant with all medications prescribed by my mental health provider.

Yes

If no, please explain:

Beck Anxiety Inventory (BAI)

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, or since your last infusion if you have started the ketamine infusion therapy by selecting the appropriate answer to each symptom.

1. Numbness or Tingling

I do not feel numbness or tingling.

I mildly feeling numbness or tingling but it doesn't bother me much.

I moderately feel numbness or tingling and it wasn't pleasant.

I severly feel numbness or tingling and it bothered me a lot.

2. Feeling Hot

I do not experience feeling hot.

I mildly experience feeling hot but it doesn't bother me much.

I moderately experience feeling hot and it wasn't pleasant.

I severly experience feeling hot and it bothered me a lot.

3. Wobbliness in Legs

I do not feel wobbliness in legs.

I mildly experience wobbliness in legs but it doesn't bother me much.

I moderately experience wobbliness in legs and it wasn't pleasant.

I severly experience wobbliness in legs and it bothered me a lot.

4. Unable to Relax

I am able to relax.

I am mildly unable to relax but it doesn't bother me much.

I am moderately unable to relax and it wasn't pleasant at times.

I am severly unable to relax and it bothered me a lot.

5. Fear of Worst Happening

I do not have a fear of the worst happening.

I mildly have a fear of the worst happening but it doesn't bother me much.

I moderately have a fear of the worst and it is not pleasant at time.

I severely have a fear of the worst and it bothers me a lot.

6. Dizzy or Lightheaded

I do not feel dizziness or lightheadedness.

I mildly feel dizziness or lightheadedness but it doesn't bother me much.

I moderately feel dizziness or lightheadedness anjd it doesn't feel pleasent at times.

I severly feel dizziness or lightheadedness and it bothers me a lot.

7. Heart Pounding/Racing

I do not feel my heart pounding/racing.

I mildly feel my heart pounding/racing but it doesn't bother me much.

I moderately feel my heart pounding/racing and it doesn't feel pleasant at times.

I severly feel my heart pounding/racing and it bothers me a lot.

8. Unsteady

I do not feel unsteady.

I mildly feel unsteady but it doesn't bother me much.

I moderately feel unsteady and it doesn't feel pleasant at times.

I severly feel unsteady and it bothers me a lot.

9. Terrified or Afraid

I do not feel terrified or afraid.

I mildly feel terrified or afraid but it doesn't bother me much.

I moderately feel terrified or afraid and it doesn't feel pleasant at times.

I severly feel terrified or afraid and it bothers me a lot.

10. Nervous

I do not feel nervous.

I mildly feel nervous but it doesn't bother me much.

I moderately feel nervous and it doesn't feel pleasant at times.

I severely feel nervous and it bothers me a lot.

11. Feeling of Choking

I do not have a feeling of choking.

I mildly have a feeling of choking but it doesn't bother me much.

I moderately have a feeling of choking and it doesn't feel pleasent at times.

I severly have a feeling of choking and it bothers me a lot.

12. Hands Trembling

I do not experience hands trembling.

I mildly experience hands trembling and it doesn't feel pleasant at times.

I moderately experience hands trembling and it doesn't feel pleasant at times.

I severly experience hands trembling and it bothers me a lot.

13. Shaky/Unsteady

I do not feel shaky/unsteady.

I mildly feel shaky/unsteady but it doesn't bother me much.

I moderately feel shaky/unsteady and it doesn't feel pleasant at times.

I severely feel shaky/unsteady and it bothers me a lot.

14. Fear of Losing Control

I do not have a fear of losing control.

I midly have a fear of losing control but it doesn't bother me much.

I moderately have a fear of losing control and it doesn't feel pleasant at times.

I severly have a fear of losing control and it bothers me a lot.

15. Difficulty in Breathing

I do not have difficulty in breathing.

I midly have difficulty in breathing but it doesn't bother me much.

I moderately have difficulty in breathing and it doesn't feel pleasant at times.

I severly have difficulty in breathingand it bothers me a lot.

16. Fear of Dying

I do not have a fear of dying.

I mildly have a fear of dying and it doesn't bother me much.

I moderately have a fear of dying and it doesn't feel pleasant at times.

I severely have a fear of dying and it bothers me a lot.

17. Scared

I do not feel scared.

I mildly feel scared but it doesn't bother me much.

I moderately feel scared and it doesn't feel pleasant at times.

I severly feel scared and it bothers me a lot.

18. Indigestion

I do not experience indigestion.

I mildly experience indigestion and it doesn't bother me much.

I moderately experience indigestion and it doesn't feel pleasant at times.

I severely experience indigestion and it bothers me a lot.

19. Faint/Lightheaded

I do not feel faint/lightheaded.

I mildly feel faint/lightheaded but it doesn't bother me much.

I moderately feel faint/lightheaded and it doesn't feel pleasant at times.

I severely feel faint/lightheaded and it bothers me a lot.

20. Face Flushed

I do not have face flushed.

I mildly have face flushed but it doesn't bother me much.

I moderately have face flushed and it deosn't feel pleasant at times.

I severely have face flushed and it bothers me a lot.

21. Hot/Cold Sweats

I do not have hot/cold sweats.

I mildly have hot/cold sweats but it doesn't bother me much.

I moderately have hot/cold sweats and it doesn't feel pleasant at times.

I severely have hot/cold sweats and it bothers me a lot.

Beck Depression Form (BDI)

Below is a list of common symptoms of depression. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, or since your last infusion if you have started the ketamine infusion therapy by selecting the appropriate answer to each symptom.

1. Feel Sad

I do not feel sad.

I feel sad.

I am sad all the time and I can't snap out of it.

I am so sad and unhappy that I can't stand it.

2. Discouraged about the future.

I am not particularly discouraged about the future.

I feel discouraged about the future.

I feel I have nothing to look forward to.

I feel the future is hopeless and that things cannot improve.

3. Feel like a failure.

I do not feel like a failure.

I feel I have failed more than the average person.

As I look back on my life, all I can see is a lot of failures.

I feel I am a complete failure as a person.

4. Feel Satisfied

I get as much satisfaction out of things as I used to.

I don't enjoy things the way I used to.

I don't get real satisfaction out of anything anymore.

I am dissatisfied or bored with everything.

5. Feel Guilty

I don't feel particularly guilty.

I feel guilty a good part of the time.

I feel quite guilty most of the time.

I feel guilty all of the time.

6. Feel Punished

I don't feel I am being punished.

I feel I may be punished.

I expect to be punished.

I feel I am being punished.

7. Feel Disappointment

I don't feel disapointed in myself.

I am disappointed in myself.

I am disgusted with myself.

I hate myself.

8. Self Criticism

I don't feel I am any worse than anybody else.

I am critical of myself for my weaknesses or mistakes.

I blame myself all the time for my faults.

I blame myself for everything bad that happens.

9. Suicidal Thoughts

I don't have any thoughts of killing myself.

I have thoughts of killing myself, but I would not carry them out.

I would like to kill myself.

I would kill myself if I had the chance.

10. How often I cry

I don't cry more than usual.

I cry more now than I used to.

I cry all the time now.

I used to be able to cry, but now I can't cry even though I want to.

11. Irritability

I am no more irritated by things than I ever was.

I am slightly more irritated not than usual.

I am quite annoyed or irritated a good deal of time.

I feel irritated all the time.

12. Social Interests

I have not lost interest in other people.

I am less interested in other people than I used to be.

I have lost most of my interest in other people.

I have lost all of my interest in other people.

13. Decision Making

I make decisions about as well as I ever could.

I put off making decisions more than I used to.

I have greater difficulty in making decisions more than I used to.

I can't make decisions at all anymore.

14. Self Image

I don't feel that I look any worse than I used to.

I am worried that I am looking old or unattractive.

I feel there are permanent changes in my appearance that make me look unattractive.

I believe that I look ugly.

15. Work Ethic

I can work about as well as before.

It takes an extra effort to get started at doing something.

I have to push myself very hard to do anything.

I can't do any work at all.

16. Sleep

I can sleep as well as usual.

I don't sleep as well as I used to.

I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.

I wake up several hours earlier than I used to and cannot get back to sleep.

17. Exhaustion

I don't get more tired than usual.

I get tired more easily than I used to.

I get tired from doing almost anything.

I am too tired to do anything.

18. Appetite

My appetite is no worse than usual.

My appetite is not as good as it used to be.

My appetite is much worse now.

I have no appetite at all anymore.

19. Change in Weight

I haven't lost much weight, if any, lately.

I have lost more than five pounds.

I have lost more than ten pounds.

I have lost more than fifteen pounds.

20. Health Concerns

I am no more worried about my health than usual.

I am worried about physical problems like aches, pains, upset stomach, or constipation.

I am very worried about physical problems and it's hard to think of much else.

I am so worried about my physical problems that I cannot think of anything else.

21. Intimacy

I have not noticed any recent change in my interest in sex.

I am less interested in sex than I used to be.

I have almost no interest in sex.

I have lost interest in sex completely.

Medical History Form

Allergies:

Past Medical History:

Metabolic/Endocrine

Respiratory

GU/GI

Cardiovascular

Pain

Infectious

Hematology/Oncology

Other

Past Surgical History:

Current Medications/Supplements:

Beck Anxiety Inventory (BAI)

Beck Depression Form (BDI)