mHBOT Intake Form

  • mHBOT Intake Form

    Client Intake Form

  • The information requested below will assist us in providing you with safe treatments. Please ask your specialist if you have any questions about the information being requested. All information provided below will be kept as confidential unless allowed or required by law. Your written permission will be required to release any information.

  • Client Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Employment*
  • Marital status*
  • Are you currently under a medical provider's care for any condition?*
  • Do you have a prescription for mild hyperbaric oxygen therapy?*

  • Social History

    Check one for each
  • Tobacco Use*
  • Vape Use*
  • Drug Use*
  • Alcohol Use*
  • Do you have diabetes?*
  • Have you ever been diagnosed with any lung/pulmonary condition?*
  • Are you experiencing or at risk for seizures or convulsions?*
  • Are you pregnant or think you may be?*
  • Have you ever had ear problems?*
  • Do you have problems with your ears when you fly?*
  • Do you have any problems going up and down in an elevator?*
  • Do you or have you ever done scuba diving?*
  • Difficulty chewing or swallowing?*
  • Assistance needed for eating?*
  • Have you had a significant weight loss or weight gain?*
  • Do you have any implanted medical devices or cosmetic implants?*

  • Health Information

  • Do you have a history of treatment with one of the following drugs?*
  • Do you have a history of or currently have one of the following?*
  • Should be Empty: