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
Male
Female
PARENT’S NAME (if applicable)
ADDRESS
STREET ADDRESS
Street Address Line 2
CITY
STATE
ZIP
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
DAYTIME PHONE
Please enter a valid phone number.
RELATIONSHIP TO PATIENT
Address
STREET ADDRESS
Street Address Line 2
CITY
STATE
ZIP
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
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
SPECIALTY
ADDRESS
STREET ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PHONE
Please enter a valid phone number.
FAX
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
1. CURRENT MEDICATIONS
List all medicines you are currently taking including prescription and over-the-counter
2. ALLERGIES
Please list all known allergies
3. 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
4. PULMONARY LUNG DIAGNOSIS
HAVE YOU EVER BEEN DIAGNOSED WITH ANY LUNG / PULMONARY CONDITION, OR PULMONARY FIBROSIS?
Yes
No
IF YES, WHAT IS THE CONDITION?
5. SEIZURE OR CONVULSION ACTIVITY
ARE YOU EXPERIENCING SEIZURES OR CONVULSIONS OR HAVE YOU BEEN TOLD THAT YOU ARE AT RISK FOR SEIZURES?
Yes
No
IF YES, WHAT IS THE CONDITION(S)?
6. PREGNANCY STATUS
ARE YOU PREGNANT OR THINK YOU COULD BE?
Yes
No
7. EAR HISTORY
a) HAVE YOU EVER HAD EAR PROBLEMS?
Yes
No
b) DO YOU HAVE ANY PROBLEMS WITH YOUR EARS WHEN YOU FLY?
Yes
No
c) DO YOU HAVE ANY PROBLEMS GOING UP AND DOWN IN AN ELEVATOR?
Yes
No
d) DO YOU OR HAVE YOU EVER DONE SCUBA DIVING?
Yes
No
e) DO YOU KNOW HOW TO EQUALIZE PRESSURE IN YOUR EARS?
Yes
No
8. MEDICAL IMPLANTS
DO YOU HAVE ANY IMPLANTED MEDICAL DEVICES?
Yes
No
IF YES, PLEASE DESCRIBE THE DEVICE, MANUFACTURER AND DATE IMPLANTED.
9. NUTRITION PROFILE
a) DO YOU HAVE DIFFICULTY CHEWING OR SWALLOWING?
Yes
No
b) DO YOU NEED ASSISTANCE FOR EATING?
Yes
No
c) HAVE YOU HAD A LARGE WEIGHT LOSS OR WEIGHT GAIN?
Yes
No
IF YES: lbs
IF YES: months
IF YES, REASON (IF KNOWN)
d) DO YOU HAVE A SPECIAL DIET?
Yes
No
IF YES, PLEASE EXPLAIN:
e) DO YOU HAVE ANY FOOD ALLERGIES OR SENSITIVITIES?
Yes
No
IF YES, PLEASE EXPLAIN:
f) ARE YOU INVOLVED IN A WEIGHT LOSS PROGRAM?
Yes
No
IF YES, PLEASE EXPLAIN:
g) HOW IS YOUR APPETITE?
Good
Fair
Poor
h) HOW MUCH WATER DO YOU DRINK EACH DAY?
glasses
i) DO YOU EXERCISE REGULARLY?
Yes
No
j) DO YOU TAKE VITAMINS OR SUPPLEMENTS
Yes
No
IF YES, LIST ALL VITAMINS AND/OR SUPPLEMENTS TAKEN
Submit
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