KAP Medical Intake Form KAP Medical Intake Form Email * Name * Name First First Last Last Date of Birth * Do you have an allergies to medications and/or a have history of adverse reactions to immunizations? * Do you have an allergy to Latex? * Yes No Please list all current prescribed medications: * Please list any diseases, medical conditions, or medical abnormalities: * Any history of head trauma or seizures? If yes, please explain: * Do you have a history of the following? * Hypertension that is not well controlled (e.g., repeated systolic BP ≥140 or diastolic BP ≥90) Poorly controlled glaucoma Abnormal labs or blood work Abnormal EKG Low blood pressure Hyperthryroidism None of the above Do you have a history of a chronic medical condition related to kidney, liver, respiratory, or cardiac function? * Yes No If yes, please briefly describe medical condition. Are you pregnant or breast feeding? * Yes No Are you taking any of the following medications? * Beta blockers (ex. metoprolol succinate, metoprolol tartrate, Atenolol (Tenormin), Propranolol (inderal) Benzodiazapines (ex. Ativan (lorazepam), Xanax (alprazolam), Klonopin (clonazepam) MAOI antidepressant medications (ex. Nardil (phenelzine), Emsam (selegiline), Marplan (isocarboxazid) Stimulant medications (ex. Adderall, Ritalin, Concerta, Vyvanse) Lamictal (lamotrigine) None of the above Have you been diagnosed with any of the following? * Depressive disorder Anxiety disorder Posttraumatic Stress Disorder Bipolar Depression (I or II) Eating disorder Other Please give a brief explanation of other diagnosis: Have you found two or more medications for the above diagnoses to be ineffective? If so, please explain. * Do you have a diagnosis of schizophrenia or a history of manic episodes? If yes, please describe? * Do you struggle with getting adequate sleep or insomnia? If so please describe sleep issues. * If you drink alcohol, on average how many alcoholic drinks a week do you consume? Do you smoke or consume THC or CBD * Yes No Do you smoke or consume tobacco products? * Yes No Do you have experience with psychedelics in a therapeutic or recreational setting? If so please briefly describe. * If you are human, leave this field blank. Submit
