Name *

First Name

Last Name

Phone

(###)

###

####

Are you pregnant or breastfeeding? *

Yes

No

Are you planning to become pregnant soon? *

Yes

No

Do you have a known or suspected allergy to ketamine? *

Yes

No

Are you currently prescribed Ketamine or eskatime? *

Yes

No

Do you have history of uncontrolled hypertension or cardiac disease (prior MI, cardiac stents or bypass surgery)? *

Yes

No

Have you ever been diagnosed with increased intracranial pressure, a venous malformation, or aneurysm? *

Yes

No

Have you ever been diagnosed with increased intraocular pressure, or glaucoma? *

Yes

No

Do you have a history of cerebral hemorrhage or brain bleeding? *

Yes

No

Do you have neurologic, respiratory, or hemodynamic compromise? *

Yes

No

Do you have known renal or liver failure? *

Yes

No

Have you ever been diagnosed with Major Depressive Disorder (MDD) or Post Traumatic Stress Disorder (PTSD)? *

Yes

No

Have you been previously diagnosed with Schizophrenia or Schizoaffective Disorder? *

Yes

No

Have you ever been diagnosed with a personality disorder? *

Yes

No

Have you required antipsychotics-prescription or PRN by emergency providers or emergent administration of other mood-altering medications for the management of acute agitation? *

Yes

No

Are you currently taking any of the following medications or substances? *

Mood stabilizers/Seizure medication

Anti-psychotics

Hypertension medication

Benzodiazepines

Cannabis

Opioids

Alcohol

None