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Amber Grob
Jenna Derosa
Jenna Garzoni
Emma Fitzpatrick
Abby Fellure
Jessica Orszulak
Sara Holing
Shonnette Bennett
Contact
Specialty Treatments
Brainspotting
Spravato (Esketamine) Therapy
Appointments
Simple Practice Portal
Ketamine Intake Form
Featured In
Shoutout Colorado
Our Services
About Us
Amber Grob
Jenna Derosa
Jenna Garzoni
Emma Fitzpatrick
Abby Fellure
Jessica Orszulak
Sara Holing
Shonnette Bennett
Contact
Specialty Treatments
Brainspotting
Spravato (Esketamine) Therapy
Appointments
Simple Practice Portal
Ketamine Intake Form
Featured In
Shoutout Colorado
Patient Demographics
Last Name:
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First Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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DOB:
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Email:
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Insurance Info
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Policy ID:
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Medical History Part 1
Do you have any allergies?
Yes
No
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Do you have any adverse drug reactions?
Yes
No
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List medical diagnosis (i.e. Asthma, diabetes, high blood pressure etc.):
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Medications
Medication Name:
Diagnosis:
Dosage:
How Often:
Add another medication
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Medical History Part 2
How much alcohol do you consume:
Must give an answer
List any recreational drugs you use:
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Do you you use any tobacco/nicotine products?
Yes
No
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Do you suffer from chronic pain?
Yes
No
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List any chronic pain meds:
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Medical History Part 3
Name of Primary Care Provider:
Name of Therapist:
Names of any other specialists seen (pain, endocrine, etc):
When/Where was your last blood draw:
Are your immunizations up to date, including covid?
Yes
No
A selection is required.
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Psychiatric History
List the previous psychiatrists you have seen in the last 5 years:
List the previous therapists you have seen in the last 5 years:
List any psychiatric disorders you have been diagnosed with:
List any psychiatric hospitalizations:
In the past, have you tried electroconvulsion therapy (ECT)?
Yes
No
A selection is required.
In the past, have you tried TMS?
Yes
No
A selection is required.
List any previous treatments with Ketamine or Esketamine:
Have you done a genetic testing for psychotropic medications?
Yes
No
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Past Pysch Medications
If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember). When describing the reason stopped please indicate whether it was ineffective or if you experience side effects and if so, what side effects.
Antidepressants
Prozac (fluoxetine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Zoloft (sertraline)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Luvox (fluvoxamine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Paxil (paroxetine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Celexa (citalopram)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Lexapro (escitalopram)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Effexor (venlafaxine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Cymbalta (duloxetine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Wellbutrin (bupropion)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Remeron (mirtazapine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Serzone (nefazodone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Anafranil (clomipramine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Pamelor (nortrptyline)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Tofranil (imipramine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Elavil (amitriptyline)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Mood Stabilizers
Tegretol (carbamazepine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Lithium
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Depakote (valproate)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Lamictal (lamotrigine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Topamax (topiramate)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Antipsychotics
Haldol (haloperidol)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Loxitane (loxapine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Mellaril (thioridazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Moban (molindone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Navane (thiothixene)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Prolixin (fluphenazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Serentil (mesoridazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Stelazine (trifluoperazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Thorazine (chlorpromazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Trilafon (perphenazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Abilify (aripiprazole)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Clozaril (clozapine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Risperdal (risperidone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Seroquel (quetiapine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Zyprexa (olanzepine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Geodon (ziprasidone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Rexulti (Brexpiprazole)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Vraylar (Cariprazine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Sedatives/Hypnotics
Ambien (zolpidem)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Sonata (zaleplon)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Rozerem (ramelteon)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Restoril (temazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Desyrel (trazodone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
ADHD Medications
Adderall (amphetamine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Concerta (methylphenidate)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Ritalin (methylphenidate)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Strattera (atomoxetine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Vyvanse (Lisdexamfetamine)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Antianxiety Medications
Xanax (alprazolam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Ativan (lorazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Klonopin (clonazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Valium (diazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Tranxene (clorazepate)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Buspar (buspirone)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Centrax (prazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Librium (chlordiazepoxide)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Inderal (propranolol)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Serax (oxazepam)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Tenormin (atenolol)
Date Started:
Date Ended:
Dosage:
Reason Stopped:
Hydroxyzine
Date Started:
Date Ended:
Dosage:
Reason Stopped:
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