Returning Client Form

Welcome back to Be Well Ketamine Institute.

Please complete this short evaluation form before your visit. Your responses help our clinical team monitor your progress and adjust your Ketamine Infusion Therapy treatment plan if needed.

Your answers help ensure your care remains personalized, safe, and effective.

Patient Information

First Name *

Last Name *

Email *

Date of Visit *

Number of previous ketamine treatments *

Symptom Tracking

Scale Guide

0 = No symptoms / feeling great 😄
5 = Moderate symptoms
10 = Severe symptoms / worst it has been 😭

To help both you and your provider track your treatment progress, please rate your symptoms before your last treatment, since your last treatment, and how you feel today before your session.

Before Your Last Treatment *

Depression
Anxiety
Mood
Pain level
Sleep quality
Overall well-being

Since Your Last Treatment *

Depression
Anxiety
Mood
Pain level
Sleep quality
Overall well-being

Today (Before Today’s Treatment) *

Depression
Anxiety
Mood
Pain level
Sleep quality
Overall well-being

Treatment Effects

Duration of Treatment Benefits

Side Effects

Medication Updates

Have there been any changes to your medications since your last visit? *

Yes

No

Lifestyle & Daily Function

Since your last treatment:

Additional Notes

By checking this box, I consent to receive non-marketing text messages from Be Well Ketamine Institute regarding appointment reminders, treatment updates, and important information related to my care. Message frequency may vary. Message and data rates may apply. Text HELP for assistance. Reply STOP to opt out at any time.

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215 Cajon St

Redlands, CA 92373

(909) 414-7616

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