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PAT Assessment Form
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Check all conditions that apply:
Pregnant
Breastfeeding
Cardiovascular Issues
Diabetes
Epilepsy or history of seizures
Schizophrenia
Bipolar Type 1
Borderline Personality Disorder
Psychotic episodes or hospitalized for psychotic condition
Are you currently taking any of the following medications?
Lithium
Anti-psychotics
Antidepressants
Anti-anxiety medications
Benzodiazepines
Opiates
If any conditions or medications were checked above, please provide details about the condition or the medication...
When was the last time you ingested psychedelics? Which psychedelics did you take and how much did you take?
On a scale of 1 - 10 (10 being highest), how would you rate yourself with respect to having control issues.
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