Hyperbaric Oxygen Therapy Patient Intake Form
TODAY'S DATE
*
-
Month
-
Day
Year
Date
PERSONAL INFORMATION
PATIENT'S NAME
*
First Name
Last Name
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
AGE
*
SEX
*
Female
Male
PARENT'S NAME (If applicable)
First Name
Last Name
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOME PHONE
*
Please enter a valid phone number.
CELL PHONE
*
Please enter a valid phone number.
BUSINESS PHONE
Please enter a valid phone number.
E-MAIL ADDRESS
*
example@example.com
MARITAL STATUS
*
Minor
Single
Married
Separated
Divorced
Widowed
EMPLOYMENT
*
Minor
Full-time
Part-time
Unemployed
Disabled
Retired
EMERGENCY CONTACT
NAME
*
First Name
Last Name
DAYTIME PHONE
*
Please enter a valid phone number.
RELATIONSHIP TO PATIENT
*
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERRAL
HOW DID YOU HEAR ABOUT OUR FACILITY?
*
Friend/Family
Online
Other
WHO CAN WE THANK FOR YOUR REFERRAL?
E-MAIL ADDRESS
example@example.com
PHONE
Please enter a valid phone number.
CURRENT HEALTH CONCERNS
*
CONCERNS (Please list in order of priority)
PREVIOUS TREATMENT
1.
2.
3.
4.
5.
PHYSICIAN
ARE YOU CURRENTLY UNDER A DOCTOR'S CARE
*
Yes
No
DID THEY RECOMMEND HYPERBARIC OXYGEN THERAPY?
*
Yes
No
DO YOU HAVE A PRESCRIPTION FOR HYPERBARIC OXYGEN THERAPY?
*
Yes
No
PHYSICIAN'S NAME
First Name
Last Name
SPECIALTY
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE
Please enter a valid phone number.
FAX
Please enter a valid fax number.
SOCIAL HISTORY
TOBACCO USE
*
Never
Previously, but quit
Currently
IF YES, # PACKS/DAY
CAFFEINE USE
*
Never
Yes
IF YES, LIST FREQUENCY & SOURCE OF CAFFEINE
ALCOHOL USE
*
Never
Rarely
Moderately
Daily
DRUG USE
*
Never
Yes
IF YES, LIST FREQUENCY & TYPE OF DRUG USE
CURRENT MEDICATIONS (List all medicines you are currently taking including prescription and over-the-counter)
*
MEDICATION
DOSAGE
FREQUENCY
1.
2.
3.
4.
5.
6.
ALLERGIES (please list all known allergies)
*
DIABETES
DO YOU HAVE DIABETES?
*
Yes
No
IF YES, DO YOU TAKE:
Insulin
Oral agents
Diet controlled
IF YES, HOW OFTEN DO YOU TEST YOUR BLOOD SUGAR?
time(s)/day
PULMONARY LUNG DIAGNOSIS
HAVE YOU EVER BEEN DIAGNOSED WITH ANY LUNG/PULMONARY CONDITION, OR PULMONARY FIBROSIS?
*
No
Yes
IF YES, WHAT IS THE CONDITION?
SEIZURE OR CONVULSION ACTIVITY
ARE YOU EXPERIENCING SEIZURES OR CONVULSIONS OR HAVE YOU BEEN TOLD THAT YOU ARE AT RISK FOR SEIZURES?
*
No
Yes
IF YES, WHAT IS THE CONDITION(S)?
PREGNANCY STATUS
ARE YOU PREGNANT OR THINK YOU COULD BE?
*
No
Yes
EAR HISTORY
HAVE YOU EVER HAD EAR PROBLEMS?
*
No
Yes
DO YOU HAVE ANY PROBLEMS WITH YOUR EARS WHEN YOU FLY?
*
No
Yes
DO YOU HAVE ANY PROBLEMS GOING UP AND DOWN IN AN ELEVATOR
*
No
Yes
DO YOU OR HAVE YOU EVER DONE SCUBA DIVING?
*
No
Yes
DO YOU KNOW HOW TO EQUALIZE PRESSURE IN YOUR EARS?
*
No
Yes
MEDICAL IMPLANTS
DO YOU HAVE ANY IMPLANTED MEDICAL DEVICES
*
No
Yes
IF YES, PLEASE DESCRIBE THE DEVICE, MANUFACTURER AND DATE IMPLANTED
NUTRITION PROFILE
DO YOU HAVE DIFFICULTY CHEWING OR SWALLOWING?
*
No
Yes
DO YOU NEED ASSISTANCE FOR EATING?
*
No
Yes
HAVE YOU HAD A LARGE WEIGHT LOSS OR WEIGHT GAIN?
*
No
Yes
IF YES:
lbs.
months
IF YES, REASON (IF KNOWN):
Type a label
DO YOU HAVE A SPECIAL DIET
*
No
Yes
IF YES, PLEASE EXPLAIN:
DO YOU HAVE ANY FOOD ALLERGIES OR SENSITIVITIES?
*
No
Yes
IF YES, PLEASE EXPLAIN:
ARE YOU INVOLVED IN A WEIGHT LOSS PROGRAM?
*
No
Yes
IF YES, PLEASE EXPLAIN:
HOW IS YOUR APPETITE?
*
Good
Fair
Poor
HOW MUCH WATER DO YOU DRINK EACH DAY?
*
glasses
DO YOU EXERCISE REGULARLY
*
No
Yes
DO YOU TAKE VITAMINS OR SUPPLEMENTS?
*
No
Yes
IF YES, LIST ALL VITAMINS AND/OR SUPPLEMENTS TAKEN
*
SUPPLEMENT
DOSAGE
FREQUENCY
1.
2.
3.
4.
5.
Submit
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