Esketamine (Spravato) Eligibility Assessment Tool

Patient Information

Patient's Legal Name(Required)

First Last

Patient's Preferred Name

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Patient's Gender

Male

Female

Other

Gender, if other

Patient's Email(Required)

Enter Email Confirm Email

Patient's Phone(Required)

Do we have permission to text you on this phone number?(Required)

Yes

Patient's Address

Primary Insurance Provider(Required)

Insurance ID Number(Required)

Part 1: PHQ-9 Questionnaire

For each of the following questions, please indicate the frequency of each symptom by selecting your experience over the last two weeks:

Little interest or pleasure in doing things?(Required)

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless?(Required)

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much?(Required)

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy?(Required)

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating?(Required)

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down?(Required)

Not at all

Several days

More than half the days

Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television?(Required)

Not at all

Several days

More than half the days

Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual?(Required)

Not at all

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way?(Required)

Not at all

Several days

More than half the days

Nearly every day

Total PHQ-9 Score:

PHQ-9 Score Interpretation: Mild (5–9), Moderate (10–14), Moderately Severe (15–19), Severe (20+)

Part 2: Treatment History

Medication History

How many different antidepressant medications have you tried in this current depressive episode?(Required)

Please list each medication and duration (weeks/months) you were on it:

Medication

Duration

Did you respond to any of these treatments?

Yes

Not applicable

Psychotherapy History

Have you participated in psychotherapy during this depressive episode? (Check all that apply)

Cognitive Behavioral Therapy (CBT)

Interpersonal Therapy (IPT)

Dialectical Behavior Therapy (DBT)

Other

if other(s)(Required)

How many weeks or months did you participate in therapy?(Required)

Part 3: Duration of Current Depression

Duration of Depressive Episode

When did your current depressive episode begin? (Month/Year)(Required)

Have you had any thoughts of suicide or self-harm in the last month?(Required)

Yes

Total duration (in months or years) of depressive symptoms:(Required)

Part 4: Suicide Risk Assessment

Suicidal Ideation

Have there been any periods of symptom improvement during this time?(Required)

Yes

Have you attempted suicide in the past?(Required)

Yes

Are there any current plans or intent related to self-harm?(Required)

Yes

Severity of Suicidal Thoughts

Hidden

Score on Question 9 of the PHQ-9 (from Part 1):(Required)

Frequency of suicidal thoughts(Required)

Occasional

Frequent

Constant

Part 5: Contraindications

Medical Contraindications (Check any that apply)

Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels)

Arteriovenous malformation

History of intracerebral hemorrhage

Known hypersensitivity to esketamine or any of its components

Pregnant or breastfeeding

History of or active psychosis

Severe substance use disorder (active or recent)

Unstable medical conditions that may affect mental state

HIPAA Disclaimer:

Your privacy and confidentiality are important to us. By submitting this form, you acknowledge that the information provided will be handled in accordance with HIPAA regulations. We are committed to protecting your personal health information and ensuring it remains confidential. Please avoid sharing sensitive health details unless necessary for your inquiry.

Esketamine (Spravato) Eligibility Assessment Tool

Esketamine (Spravato) Eligibility Assessment Tool

Esketamine (Spravato) Eligibility Assessment Tool

Patient Information

Part 1: PHQ-9 Questionnaire

Part 2: Treatment History

Part 3: Duration of Current Depression

Part 4: Suicide Risk Assessment

Part 5: Contraindications

HIPAA Disclaimer:

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