Patient Intake Form - Ketamine Wellness Centers

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Ketamine Wellness Centers

Ketamine Treatments Phoenix, Arizona

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Treatments
Locations
Insurance
Patient Resources
Forms
About
Blog
Contact
- Careers

Patient Intake Form

For optimal user experience, we recommend completing this form on a computer or tablet. If you have any questions about the patient intake form, our staff is available during regular business hours to assist at 855-KET-WELL.

Personal Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Do you give our staff permission to leave a voicemail regarding your inquiry into Ketamine Wellness Centers in the event we cannot reach you?*
Email*
Preferred Contact Method*
How did you find us?*
Emergency Contact Name*
Emergency Contact Phone*
What condition(s) are you seeking treatment for at our clinic?*
Please mark all that apply
- Depression
- Post Traumatic Stress Disorder (PTSD)
- Obsessive Compulsive Disorder (OCD)
- Anxiety
- Suicidal Ideation
- Chronic Pain
- Other
Which KWC clinic location would you like to receive treatment at?*
Health Information
List any discontinued medications and the corresponding dose*
If none, type "n/a" or "none"
List any current medications and the corresponding dose*
If none, type "n/a" or "none"
Please list any known allergies*
If none, type "n/a" or "none"
Please list any surgical procedure(s)s and approximate date(s)*
If none, type "n/a" or "none"
Please list any or all anesthesia problems with you or your family members*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Neurological/Brain conditions (stroke, epilepsy, concussions, etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Cardiac/Heart conditions (high blood pressure, heart attack, heart murmur, etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Gastro/Liver/Intestinal conditions (crohn's, IBS, hepatitis, etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Endocrinology (Cancer, Diabetes, Thyroid etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Renal/Kidney conditions (renal failure, dialysis etc.)
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Pulmonary/Lung conditions (asthma, COPD, tobacco use, etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Orthopedic/Bone conditions (fractures, rheumatoid arthritis, osteo-arthritis etc.)*
If none, type "n/a" or "none"
Please list all current or resolved conditions regarding Other conditions (Fibromyalgia, Pain Syndromes, Chronic Pain, Glaucoma etc.)*
If none, type "n/a" or "none"
Personal & Lifestyle
Marriage Status*
Children?*
Number of People in Your Household and Their Age(s)*
Occupation and Employer*
Highest Level of Education*
List of Hobbies*
Do you exercise regularly?*
How Many Meals do you Eat per day?*
Are you happy with your weight?*
When was the last time you drank alcohol, what type and how much?*
Are you concerned about your alcoholic intake?*
List any non-prescribed and/or illicit drug use*
If none, type "n/a" or "none"
In the last year have you drank alcohol or used drugs more than you meant to?*
Have you wanted/needed to cut down on your drinking or drug use in the last year?*
In the last year have you used alcohol or non-prescription drugs to deal with feelings of frustration or stress?*
As a result of drinking or drug use has anything happened in the last year that you wished hadn't happened?*
Are you happy with your sex life?*
Describe the stressors in your life.*
I am not happy with*
- Myself
- My Partner
- My Health
- My Work
- My Life History
- My Suicide Attempt
- Not Applicable
Please check the boxes related to the following conditions for Depression*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please check the boxes related to the following conditions for PTSD*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please check the boxes related to the following conditions for Schizophrenia*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please check the boxes related to the following conditions for Suicidality*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please check the boxes related to the following conditions for Drug Abuse*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please check the boxes related to the following conditions for Alcohol Abuse*
- Self
- Mother
- Father
- Siblings
- Significant Other
- Not Applicable
Please add any other pertinent health information below
Did a current patient refer you to KWC?
If so, please enter their name below so that they may benefit from our referral program.
Did a medical professional refer you to KWC?
If so, please list their name/practice below.
Please provide a digital signature below:*
I confirm that, to the best of my knowledge, this document accurately reflects my personal health information.

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Ketamine Wellness Centers

Ketamine Wellness Center’s mission is to provide personalized, compassionate, high-quality care for people suffering from afflictions where Ketamine infusions have proven a successful treatment option (Depression, Chronic Pain, PTSD, OCD, Suicidality) while actively researching Ketamine’s efficacy to treat additional conditions. There is hope. There is help.

PHONE:
855-KET-WELL (1-855-538-9355)
FAX:
844-KET-WELL (1-844-538-9355)
CLINIC LOCATIONS:
Chicago, Illinois
603 E Diehl Rd, Suite #139 Naperville, IL 60563
Dallas-Fort Worth, Texas
6144 Precinct Line Road, Suite 100 Hurst, TX 76054
Denver, Colorado
7261 S Broadway, Suite 10-L Littleton, CO 80122
Houston, Texas
12807 Haynes Rd. Building A, Unit 1 Houston, TX 77066
Jacksonville, Florida
3753-2 Cardinal Point Drive Jacksonville, FL 32257
Minneapolis-St Paul, Minnesota
11995 County Road 11, Suite 220 Burnsville, MN 55337
Mesa-Gilbert, Arizona
2451 E. Baseline Rd, Suite 300 Gilbert, AZ 85234
Seattle, Washington
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003
Tucson, Arizona
3130 N Swan Rd. Tucson, AZ 85712
Las Vegas, Nevada
7375 S. Pecos Rd. Suite 102 Las Vegas, NV 89120
Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT 84123
Phoenix, Arizona
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012
Reno, Nevada
1895 Plumas St. #6 Reno, NV 89509

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