Questionnaire survey

Questionnaire Ketamine Treatment

Patient identification

Please indicate first and last letter of surname, first letter of first name and year of birth (ex: Franz Müller -> mrf1958)* OR firstnamelastname (ex: FranzMüller)

Please enter the first and last letter of the surname, the first letter of the first name and the year of birth (e.g. Franz Müller -> mrf1958).*

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Amount of ketamine (in mg):*

Incorrect input

What phenomena could you perceive during the last ketamine treatment?

Dreams/visions/images/spiritual experience (0 = not at all, 10 = very intense)*

Wrong input!

Feeling outside the body (0 = not at all, 10 = very intense)*

Wrong input!

Feeling of "floating" (0 = not at all, 10 = very intense)*

Wrong input!

Dizziness (0 = not at all, 10 = very intense)*

Wrong input!

Nausea (0 = not at all, 10 = very intense)*

Wrong input!

Pain (0 = none, 10 = very intense)*

Wrong input!

Invalid Input

What was the ambience and support like?

Invalid Input

What could be additionally helpful?

Invalid Input

What else did you notice during this time?

Incorrect input

Please confirm:*

I agree to the processing of my data for statistical purposes. Please confirm!

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