Testform Step 1 of 4 25% Personal InformationDate* MM slash DD slash YYYY Name* First Middle Last Age*Please enter a number from 0 to 100.Gender* Male Female Other Home Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Mobile PhoneMay we text you about appointments, etc? Yes No Weight*Height*Enter two digits for inches. Ex. 5 ft 07 inchEmail* Enter Email Confirm Email Your email will not be shared with any 3rd partyDate of Birth* MM slash DD slash YYYY Please answer the below screening questions to the best of your abilityWhich of the following treatments are you interested in?* Ketamine NAD+, NR, or Niagen SGB (Stellate Ganglion Block) for PTSD Other SGB for PTSD selected*If other, please describe:*For what diagnosis are you seeking the above treatment for? Please tell us more about your symptoms and history.Have you been diagnosed with depression?* Yes No What treatments have you undergone?Antidepressant medsPsychotherapyKetamineElectroconvulsive Therapy (ECT)Transcranial Magnetic Stimulation (TMS)OtherIf other, please list and commentDo you have a chronic pain condition?* Yes No If Yes, please explain…Have you ever been treated for any other psychiatric condition?* Yes No If Yes, please explain…Do you have a history of brain or other intracranial disease or cancer?* Yes No If Yes, please explain…Do you have any history of migraine headaches?* Yes No If Yes, please explain…Do you have any history of seizures?* Yes No If Yes, please explain…Do you have high blood pressure or heart disease?* Yes No If Yes, please explain…Are you taking medication for blood pressure or heart disease? Yes No Are you currently physically dependent on narcotics?* Yes No If Yes, please explain…Recreational drug use?* Yes No If Yes, please explain…Are you currently pregnant or breastfeeding?* Yes No Have you had bloodwork done in the past 6 months?* Yes No Do you have any allergies to medication?* Yes No If Yes, Please explain…Are you currently taking any type of medication?* Yes No Please provide a list of ALL of your CURRENT medications including name, dosage, frequency, and condition used for:*Please provide a list of all of your PAST psychiatric medications. You do not need to provide doses for these.* Primary Care PhysicianPrimary Care Physician NamePrimary Care Physician AddressPrimary Care Physician Phone NumberPsychiatrist or Mental Health ProfessionalPsychiatrist or Mental Health Professional NamePsychiatrist or Mental Health Professional AddressPsychiatrist or Mental Health Professional Phone NumberHave you discussed ketamine treatment with your psychiatrist or mental health provider? Yes No Emergency InformationEmergency Contact NameEmergency Contact RelationshipEmergency Contact AddressEmergency Contact Phone NumberHow did you hear about us?*NBC5 TV ChicagoWGN Radio 720 AMWGN-TVWLS Radio 890 AM or 94.7 FMWBBM Radio 780 AM or 105.9 FMROCK 95.5 FM RadioThe Angi Taylor Morning Show (ROCK 95.5 FM)Google SearchMy doctor/providerFriends/FamilyOtherIf Other:* Δ Test Form Page
