Depression Index

Ketamine Wellness Centers

Ketamine Treatments Phoenix, Arizona

If you have any questions about this form, our staff is available during regular business hours (Mon - Fri, 9am - 6pm) to assist. Call us at 855-KET-WELL.

Name*
First Last
Email*
Phone*
Patient Data
I feel tired, despite sleeping 8-10 hours.*
Most of the Time Some of the time Rarely Never
I have had a significant change in appetite or interest in food.*
Most of the Time Some of the time Rarely Never
I prefer to be alone.*
Most of the Time Some of the time Rarely Never
I avoid being around friends or family.*
Most of the Time Some of the time Rarely Never
I avoid activities that are positive to my health such as eating healthy, exercising, or attending routine doctor visits.*
Most of the Time Some of the time Rarely Never
I have trouble sleeping.*
Most of the Time Some of the time Rarely Never
I think about ending my life.*
Most of the Time Some of the time Rarely Never
I feel my family and friends would be better off without me.*
Most of the Time Some of the time Rarely Never
I feel there is nothing to look forward to in my future.*
Most of the Time Some of the time Rarely Never
I have feelings of guilt or shame.*
Most of the Time Some of the time Rarely Never
I drink or use drugs to excess.*
Most of the Time Some of the time Rarely Never
I have stopped participating in activities or attending my house of worship*
Most of the Time Some of the time Rarely Never
I suffer from unwanted thoughts I cannot control.*
Most of the Time Some of the time Rarely Never
I think about my problems or mistakes I have made in the past.*
Most of the Time Some of the time Rarely Never
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Depression Index

Patient Data