Patient Name
*
First Name
Last Name
Date of Birth (mm/dd/yyyy)
*
MM
DD
YYYY
Patient Phone Number
(###)
###
####
Patient Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient Email
*
Caregiver's Name (if applicable)
Caregiver's Phone Number (if applicable)
Mental Health Provider
*
Mental Health Provider Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mental Health Provider Phone
*
(###)
###
####
Mental Health Provider Fax
(###)
###
####
Mental Health Provider Email
*
The patient has been diagnosed with
*
If you haven't been officially diagnosed with one of these two options, please stop filling out this form. You don't meet the current requirements for Spravato.
Medical/Treatment History
*
Please list the name, dosage and start date for any current mental health medications (must have at least one current oral antidepressant medication)
*
Please list the name, dosage, start date and stop date for any previous mental health medications (must have tried and failed at least two previous mental health medications)
*
1. Little interest of pleasure doing things?
*
2. Feeling down, depressed, or hopeless
*
3. Trouble falling or staying asleep, or sleeping too much
*
4. Feeling tired or having little energy
*
5. Poor appetite or overeating
*
6. Feeling bad about yourself or that you're a failure or have let yourself or your family down
*
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
*
9. Thoughts that you would be better off dead, or thoughts of hurting yourself
*
Total Score (Add up your answers from #1-9 for a total).
*
