Everything will be fine at the New Energy Medical Center - Questionnaire Pre-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).*

Invalid Input

How have you felt in the last 7 days or so?

Motivation/ drive (0 = none, 10 = very strong)*

Wrong input!

State of health, mood (0 = bad mood, 10 = very good mood)*

Wrong input!

Sense of meaninglessness, unpleasant inner emptiness (0 = not at all, 10 = very intense)*

Wrong input!

Concentration problems (0 = not at all, 10 = very intensive)*

Wrong input!

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

Wrong input!

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

Wrong input!

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

Wrong input!

Invalid Input

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

Wrong input!

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

Wrong input!

Invalid Input

What do you hope to achieve with the ketamine treatment?

Incorrect input

Please confirm:*

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

Questionnaire survey

Questionnaire Pre-Ketamine Treatment

Patient identification

How have you felt in the last 7 days or so?