Ketamine Infusion Treatment Referral Form Referring Psychiatrist: * Recommended Infusion Start Date: * Primary Diagnosis: * Secondary Diagnosis: * Recommended Starting Dosage: *(in mg/kg body weight) Patient Body Weight: *(in kg) Patient BMI: * Submit all completed forms below as part of consultation: *Request for Ketamine Infusion TreatmentOffice Visit NotesHealth History Form Patient Information: Last Name: * First Name: * Phone Number: * Email Address: * Address: * City: * State: *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: * Date of Birth: * Gender: *MaleFemale Primary Language: *EnglishSpanishOther Other Language: Past Medical History: * Atrial FibrillationArthritisAsthmaBleeding DisorderBlood Clots/DVTBronchitisCancerCrohn's DiseaseCOPDCongestive HeartFailureCoronary ArteryDiseaseDiabetes Type I or IIEmphysemaFibromyalgiaEpilepsyGI UlcerHeart AttackHeartburnHepatitisLiver DiseaseHigh Blood PressureHigh CholesterolHIV/AIDSKidney DiseaseLung DiseaseMental Health DiseaseMultiple SclerosisNeuropathyOrgan TransplantOsteoporosisPacemaker/DefibrillatorPTSDPulmonary EmbolusRheumatoid ArthritisSickle Cell DiseaseSleep ApneaSpine/Neck DisorderStomach UlcersStrokeThyroid DiseaseVascular Disease/Stents Are you allergic to any of the following?SteroidsPenicillinLatexIodineSulfa DrugsContrast DyeN.K.D.A If allergic, what was your reaction? Other drug allergies and reactions (if applicable): Medication List Medication Name Dosage Frequency Reason Surgical History Date Procedure / Surgery Anesthesia History Please select the following if applicable: Have you had general anesthesia or sedation before?Did you have any complications with the anesthesia?Were you told it was difficult to insert the breathing tube? Please elaborate if you checked any of the options above: Social History: Please check all that apply: I smoke tobacco productsI use alcohol Type: Number Per Day: Years Smoking: How many drinks?: How often?:
