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Intranasal EsketamineNew Patient Intake PacketThank you for your interest in Intranasal Esketamine! Please review our website to learn more about our clinic and Intranasal Esketamine to determine if we are a right fit for your psychiatric needs. Feel free to call our Intranasal Esketamine technician at 984-974-3983 if you have questions about our services or providers, and reach out directly to our financial coordinator at 984-974-3931 if you have questions about cost or insurance coverage. We ask that you work with your doctor to complete this packet in-full and mail or fax to our intake coordinators PRIOR to scheduling your Intranasal Esketamine consultation appointment. This information will allow us to have a more meaningful conversation in our initial consultation and determine how we may best cater to your specific needs as a potential TMS candidate. Thank you and we look forward to meeting you soon!Please Fax or Mail completed packet to:UNC Psychiatry Outpatient Clinic77 Vilcom Center DriveSuite #300Chapel Hill, North Carolina 27514Phone: (984)-974-3983Fax: (984)-974- 9646Intranasal EsketamineNew Patient Intake PacketPatient InformationLast Name: Middle: First Name: Date of Birth: Phone:Email: Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Nonbinary Preferred Pronouns: FORMCHECKBOX He/Him FORMCHECKBOX She/Her FORMCHECKBOX They/Them Relationship Status: FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Partner Race/Ethnicity: FORMCHECKBOX Caucasian FORMCHECKBOX African American FORMCHECKBOX Hispanic FORMCHECKBOX Asian FORMCHECKBOX Native American FORMCHECKBOX Other: Address FORMTEXT ????? Apt # FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Primary Insurance InformationInsurance Provider: Insurance Policy Holder: Insurance Number: Group Number: Relationship to Policy Holder: Policy Holder DOB: Referring ProviderTo be completed by referring provider.Referring Provider Name: Office Phone Number: Office Fax: Referral Diagnosis: FORMCHECKBOX F32.2, Major depressive disorder, single episode, severe without psychotic features FORMCHECKBOX F33, Recurrent depressive disorder FORMCHECKBOX Other: If a single episode MDD is the duration > or = 2 years? FORMCHECKBOX Yes FORMCHECKBOX No If recurrent MDD is there inadequate response to 2 different antidepressants FORMCHECKBOX Yes FORMCHECKBOX No Antidepressant #1____________ Dose _________Duration _________ Outcome___________________________Antidepressant #2____________ Dose _________Duration _________ Outcome___________________________Does the patient have a history of substance abuse? FORMCHECKBOX No FORMCHECKBOX Yes, if so where/what: Has the patient had prior ECT? FORMCHECKBOX No FORMCHECKBOX Yes, if so where/when:Has the patient had prior TMS? FORMCHECKBOX No FORMCHECKBOX Yes, if so where/when:Has the patient had prior treatment with ketamine? FORMCHECKBOX No FORMCHECKBOX Yes, if so where/when:Has the patient had vagal nerve stimulation? FORMCHECKBOX No FORMCHECKBOX Yes, if so where/when:SAFETY SCREEN FOR ESKETAMINE CANDIDATESPlease complete the following information to the best of your knowledgeQuestion:Please check the appropriate box.Do you have an allergy to ketamine? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have increased blood pressure? FORMCHECKBOX Yes FORMCHECKBOX NoAre you or have you had suicidal thoughts, plans or actions ? If yes, please describe event(s): FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with an aneurysm of the thoracic or abdominal? If yes, please describe event(s): FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with an intracranial aneurysm? If yes, please describe event(s): FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been diagnosed with a peripheral arterial aneurysm? If yes, please describe event(s): FORMCHECKBOX Yes FORMCHECKBOX NoAre you pregnant or is there a chance that you might be? FORMCHECKBOX Yes FORMCHECKBOX NoAre you breast-feeding? FORMCHECKBOX Yes FORMCHECKBOX NoAre you using contraception currently? If yes, please describe: FORMCHECKBOX Yes FORMCHECKBOX NoDo you have problems with nausea? If yes, please describe: FORMCHECKBOX Yes FORMCHECKBOX NoDo you have problems with nausea? If yes, please describe: FORMCHECKBOX Yes FORMCHECKBOX NoPSYCHIATRIC AND MEDICAL HISTORYPlease complete the following information to the best of your knowledge so that our clinic staff may best assist with the insurance prior authorization request process.Current MedicationsPlease list ALL the medications currently prescribed to you by any doctor. Please include any vitamins and/or supplements. Medication NameExample: ZoloftDosageExample: 150mg Times taken per dayExample: once each morningPsychiatric Inpatient HospitalizationsName of HospitalDates of AdmissionReason for admissionAllergiesPlease list any medication allergies below Medication NameExample: PenicillinReactionExample: Hives FORMCHECKBOX I have no known drug allergiesPast Psychiatric MedicationsIf you have ever taken any of these medications, please indicate the dates, maximum dosage, response. AntidepressantsDatesDosageResponse/side effectsProzac (fluoxetine)_______________________________________________________Zoloft (sertraline)_______________________________________________________Luvox (fluvoxamine)_______________________________________________________Paxil (paroxetine)_______________________________________________________Celexa (citalopram)_______________________________________________________Lexapro (escitalopram)_______________________________________________________Effexor (venlafaxine)_______________________________________________________Cymbalta (duloxetine)_______________________________________________________Wellbutrin (bupropion)_______________________________________________________Remeron (mirtazapine)_______________________________________________________Serzone (nefazodone)_______________________________________________________Anafranil (clomipramine)_______________________________________________________Pamelor (nortriptyline)_______________________________________________________Tofranil (imipramine)_______________________________________________________Elavil (amitriptyline)_______________________________________________________Pristiq (desvenlafaxine)_______________________________________________________Fetzima (levomilnacipran)_______________________________________________________Viibryd (vilazodone)_______________________________________________________Trintellix (vortioxetine)_________________________________________________________________________________________________________________________________Mood StabilizersDatesDosageResponse/side effectsTegretol (carbamazepine)_______________________________________________________Lithobid (lithium)_______________________________________________________Depakote (valproate)________________________________________________________Lamictal (lamotrigine)________________________________________________________Trileptal (oxcarbazepine)________________________________________________________Topamax (topiramate)________________ ________________________________________Neurontin (gabapentin)________________ ___________________________________________________________________________ ________________________________________Anti-anxiety MedsDatesDosageResponse/side effectsXanax (alprazolam)______________ ________________________________________Ativan (lorazepam)______________ ________________________________________Klonopin (clonazepam)_______________________________________________________Valium (diazepam)_____________________________________________________Atarax/Vistaril (hydroxyzine)______________________________________________________Buspar (buspirone)______________________________________________________Catapres (clonidine)______________________________________________________Minipress (prazosin)_______________________________________________________________________________________________________________________________ AntipsychoticsDatesDosageResponse/side effectsHaldol (haloperidol)________________________________________________________Clozaril (clozapine)________________ ________________________________________Seroquel (quetiapine)________________________________________________________Zyprexa (olanzapine)________________________________________________________Geodon (ziprasidone)________________________________________________________Abilify (aripiprazole)________________________________________________________Prolixin (fluphenazine)________________ ________________________________________Risperdal (risperidone)________________ ________________________________________Saphris (asenapine)________________________________________________________Invega (paliperidone)________________________________________________________Latuda (lurasidone)________________________________________________________Rexulti (brexpiprazole)________________________________________________________Vraylar (cariprazine)________________________________________________________Fanapt (iloperidone)________________________________________________________ ___________________________________________________________________________Sedative/HypnoticsDatesDosageResponse/side effectsAmbien (zolpidem)____________________________ ____________________________Sonata (zaleplon)________________ ________________________________________Rozerem (ramelteon)________________________________________________________Restoril (temazepam)________________________________________________________Desyrel (trazodone)________________________________________________________Belsomra (suvorexant)___________________________________________________________________________________________________________________________________ADHD MedsDatesDosageResponse/side effectsAdderall (amphetamine)______________________________________________________Concerta (methylphenidate)______________________________________________________Ritalin (methylphenidate)______________________________________________________Strattera (atomoxetine)______________________________________________________Vyvanse (lisdexamfetamine)______________________________________________________Intuniv (guanfacine)_______________ __________ ____________________________Dexedrine (dextroamphetamine)______________________________________________________Focalin (dexmethylphenidate)_______________________________________________________________________________________________________________________________Other Psych MedsDatesDosageResponse/side effects____________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________ _______________________________________Medical HistoryPlease circle any condition below that applies to your personal medical history and briefly explain in space provided. FORMCHECKBOX Diabetes FORMCHECKBOX Hypertension FORMCHECKBOX High Cholesterol FORMCHECKBOX Migraines FORMCHECKBOX Chronic Pain FORMCHECKBOX Acid Reflux FORMCHECKBOX Fibromyalgia FORMCHECKBOX IBS FORMCHECKBOX Thyroid Disease FORMCHECKBOX Heart Disease FORMCHECKBOX Head Injury FORMCHECKBOX Cancer FORMCHECKBOX Seizures FORMCHECKBOX Sleep Apnea FORMCHECKBOX Stroke FORMCHECKBOX Anxiety FORMCHECKBOX Depression FORMCHECKBOX ADHD FORMCHECKBOX Alzheimer’s FORMCHECKBOX Parkinson’s FORMCHECKBOX Alcohol/Drug AbuseOther:Other:Other:Other:Other:Other:Current Psychiatric SymptomsPlease check any symptoms below that you have experienced in the past 2 weeks. FORMCHECKBOX Low mood FORMCHECKBOX Tearfulness FORMCHECKBOX Hopelessness FORMCHECKBOX Euphoria FORMCHECKBOX Anxiety FORMCHECKBOX Panic attacks FORMCHECKBOX Irritability FORMCHECKBOX Guilt FORMCHECKBOX Loss of interest FORMCHECKBOX Low motivation FORMCHECKBOX Difficulty concentrating FORMCHECKBOX Withdrawn FORMCHECKBOX Insomnia FORMCHECKBOX Fatigue/ Low energy FORMCHECKBOX Nightmares FORMCHECKBOX Auditory hallucinations FORMCHECKBOX Visual hallucinations FORMCHECKBOX Paranoia FORMCHECKBOX Weight changes (gain/loss) FORMCHECKBOX Appetite changes FORMCHECKBOX Obsessive thoughts FORMCHECKBOX Other: FORMCHECKBOX Other: FORMCHECKBOX Other:Social HistoryAre you currently Employed? FORMCHECKBOX No FORMCHECKBOX Yes, if so where: Highest level of education: FORMCHECKBOX some HS FORMCHECKBOX HS/GED FORMCHECKBOX some college FORMCHECKBOX masters FORMCHECKBOX professional Military Background: FORMCHECKBOX No FORMCHECKBOX Yes, if so what branch/when: Living situation: FORMCHECKBOX With spouse/partner FORMCHECKBOX with parent(s) FORMCHECKBOX with children FORMCHECKBOX other: Do you use alcohol? FORMCHECKBOX No FORMCHECKBOX Yes, if so how many drinks per day on average in last month? Do you use tobacco products? FORMCHECKBOX No FORMCHECKBOX Yes, if so indicate type/amount per week:Servings of caffeinated drinks (coffee, tea, cola, energy drinks) per day: Family HistoryPlace a check to indicate any family members that have or have had any conditions below:FatherMotherSonsDaughtersBrothersSistersMaternalGrandmotherMaternalGrandfatherPaternalGrandmotherPaternalGrandfatherAuntsUnclesDiabetesHypertensionHeart DiseaseStrokeThyroid DiseaseDementiaSeizuresKidney DiseaseCancerAlcoholismDrug AbuseDepressionAnxiety/PanicBipolarSchizophreniaOCDADHDEating DisorderOther:Please complete the information below for each family member noted above. Living or Deceased (L/D)If deceased, age at death ................
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