Prescreening Inquiry Please fill out the following form to the best of your knowledge. First Name * Last Name * Email * What is your age? * Have you been hospitalized in the last 12 months? * NoYes Are you suffering from a medical condition, illness, or injury? * NoYes Have you been diagnosed with any of the followng: HypertensionHeart DiseaseChest PainAbnormal EKGStrokeHead TraumaSevere AsthmaRespiratory DiseaseKideny DiseaseSleep ApneaAlcohlismDrug AddictionPsychotic disorder Have you experienced any of the following? DepressionAnxietyPTSDMood SwingsDelusionsParanoiaAuditory HullucinationsSuicidal IdeationsAngerPoor ConcentrationInsomnia Are you currently taking prescribed medictions? * NoYes Are you Pregnant? * NoYes Negative reaction to anesthesia in the past? * NoYes Have you done Ketamine Therapy in the past? * NoYes Do you currently have a Therapist? * NoYes Are you a current patient at Ketadream? * NoYes If you answered yes to any question, please elaborate * Would you like us to contact you? * YesNo Provide your Phone number I agree to recieve promotional contents from this website. Please leave this field empty.
