Social Anxiety Assessment

Have you been formally diagnosed with depression?

Has a healthcare professional told you that you have social anxiety disorder?

Yes

Do you experience fear or anxiety during social interactions, such as a conversation or meeting new people?

Yes

Unsure

Do you experience fear or anxiety when you might be observed, such as while eating or drinking?

Yes

Unsure

On a scale of 0-10, with 10 being the most crippling depression you've ever felt, how depressed are you right now?

Do you experience fear or anxiety when performing in front of others, such as while speaking in front of a group of people?

Have you ever felt or do you currently feel suicidal?

Do you experience significant worrying in social situations with people you are not familiar with that is out of proportion to the threat posed?

If yes, when did you last feel suicidal?

Feel free to leave this section blank if you did not feel suicidal.

Are you currently taking medications for depression?

Do social situations almost always cause you to experience fear or anxiety?

Yes No Unsure

What other medications, supplements, or vitamins are you currently taking? (name and indication)

Do you have a history of any of the following? (Please select all that apply)

Any previous experience with ketamine, ketamine derivatives, ECT, TMS, or vagal nerve stimulation?

Do you use illicit drugs or marijuana or consume more than 3 drinks of alcohol or 3 beers more than two times a week?

Any previous experience with ketamine, ketamine derivatives, ECT, TMS, or vagal nerve stimulation?

Do you currently take any psychotropic medication like benzodiazepines or SSRIs such as clonazepam (Klonopin), alprazolam (Xanax), or Zoloft?

Yes

Unsure

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