Clinical Study Subject Screening IV Solution & Ketamine Centers of Chicago: Clinical Study Subject ScreeningThis field is hidden when viewing the formNameName(Required) First Last Date MM slash DD slash YYYY Study GroupPhone NumberEmail Gender M F AgeHeightWeightBMIAllergiesReferring ProviderPast Medical History HTN DM ASTHMA CAD STROKE SEIZURES COPD Other OtherPsych DX TRD MDD PTSD GAD BIPOLAR OCD Other OtherHave you had ketamine in any form before either as a medical treatment or recreationally?Have you had NAD+ by IV infusion or in any other form before? Yes No If Yes, when?What antidepressants or mood stabilizers have you tried before? Please list them. (Do not need doses) Add RemoveAre you pregnant, nursing, or planning to become pregnant in the next 3 months?You will have a pregnancy test before beginning the study Yes No Do you have a history or diagnosis of psychosis, schizophrenia, schizoaffective disorder, or borderline personality? Yes No Do you have a history of substance abuse?You will be drug tested before you begin the study and must refrain from all such substances, including marijuana, from the entire length of the study. Are you able and willing to do this? You will also be subject to a random drug test during the clinical study. Yes No Do you have an eating disorder like anorexia nervosa, bulimia, or other currently and in the last 5 years? Yes No Do you have a history of dementia, delirium, another cognitive brain disorder, or traumatic brain injury? Yes No Do you have hypothyroidism? Yes No And if so, is it controlled by thyroid medication? Yes No Do you have hypertension? Yes No And if so, is it controlled by medication? Yes No Do you have heart disease like congestive heart failure, coronary artery disease? Is it still controlled or treated? Yes No Are you on blood thinners? Yes No Δ
