Wyoming Wellness Center

Medical & Psychological Intake Form

Please fill out this form completely. Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name * Last Name * Date of Birth * Sex * Cell Phone * Email Address *

Additional Information

Preferred Language Emergency Contact Name * Emergency Contact Number * Who is your Primary Care Provider (PCP)? * What is the Telephone number of your PCP? *

Medical History

What is your Height? * What is your Weight? * List ALL medications you are currently taking (INCLUDING OVER THE COUNTER, VITAMINS, & SUPPLEMENTS)) * List ALL Medication ALLERGIES * List ALL Environmental/Food ALLERGIES * Medical Conditions: Please check all Medical conditions you are being treated for or have been diagnosed with * Describe ANY of the Medical Conditions OR "Any other" Conditions Marked above**Mark NA if Not Applicable** * Specific Medical Conditions: Please check ALL that you have now or in the past. * List & Describe ANY Medical Conditions you have NOT already listed Above**Mark NA if Not Applicable**

Surgical History

Please check all Surgical Procedures you have had: * Please Describe (specific name and details) of ANY other MAJOR Surgical procedures Selected Above / or Not Listed above:**Mark NA if Not Applicable** * Female and Obstetrical HISTORY *

Social / Substance History

Do you use Caffine? *Check all that Apply * Do you smoke or Vape? * Do you use chewing tobacco? Do you drink alcohol? **CHECK ALL THAT APPLY, BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details. * Do you use ANY of the following drugs? **CHECK ALL THAT APPLY, BE AS DETAILED AS POSSIBLE** We will ask for more info if you leave out details. * If "Other" Selected, Please List drug name and Dose or Amount you take**Mark NA if Not Applicable** * If you selected any drugs listed above, How often are you taking them? *

IV / IM Nutritional or Hydration Therapy - Next (3) Sections

Main Physical and Emotional Complaints - IV Nutritional Therapies **(Please check all that apply)** * Which Statements Best Describe Why You Want an IV Infusion? **(Check all that apply)** What IV Infusion / IM Injection are you requesting or interested in? *

KETAMINE for PSYCHOSOCIAL and CHRONIC PAIN TREATMENT ONLY - NEXT (12) SECTIONS

Chronic Pain - Locations and Pain Ratings

Check ALL locations of CHRONIC Pain you have below * Please rate your AVERAGE DAILY Pain * Please Rate your HIGHEST DAILY Pain *

Psychosocial / Mental Health

Please check all Psychosocial conditions you have now or have been diagnosed with in the past * Hospitalizations: Have you EVER been hospitalized for ANY of the Above check marked Conditions? * If "Yes" Marked in Last Question: PLEASE EXPLAIN - Why and When you were Hospitalized. *

Anti-Depression / Anti-Anxiety / Other Psychosocial Medication / Treatment History - Next (3) Sections

Have you Taken ANY of the Following Medications to Improve Your Mental Health **(Please check all that you have taken)** * IF You Checked "OTHER MEDICATION NOT LISTED" in Question above, Please LIST Below and EXPLAIN its Use.? **(Mark N/A if NONE)** * Have you received ANY of the following ALTERNATIVE TREATMENTS for Psychosocial Conditions? * Please Rate your AVERAGE DAILY Anxiety * Please Rate your HIGHEST DAILY Anxiety * Please Rate your HIGHEST DAILY Depression * Please Rate your AVERAGE DAILY Depression * How did you hear about Wyoming Wellness Center? *