Medical History Form

Hyperbaric Oxygen Therapy (HBOT) is a therapy that increases the amount of oxygen the body can absorb at a acellular level.

The treatment supplies oxygen in a sealed chamber at a higher-than-normal
atmospheric pressure, which allows the oxygen to dissolve more easily into liquids such as blood plasma and cerebrospinal fluids.

The body’s absorption of the increase in oxygen is reported to be beneficial for
a wide range of ailments. However, the FDA only approves HBOT therapy for certain specific conditions.

Other conditions for which HBOT often is used are considered to be “off-label”. Although many of the off-label conditions have been studied with positive results , I understand that no treatment outcome is guaranteed, and the fees I pay for the treatment are for services rendered, not for any benefits I may receive, or that I expect or hope to receive. I understand it is possible that I may not observe or realise any benefit from the treatment, and HBOT is not intended as a cure for any condition or disease.

I further understand the treatment is not a substitute for other treatment modalities suggested or prescribed by my physician.

Possible side effects of HBOT include the following: Otic barotrauma. This is ear pain or damage to the tympanic membrane caused by rapid changes in pressure, such as when a plane descends to land.

To maintain equal pressure on both sides of the tympanic membrane, gas must move freely between the nasopharynx and middle ear. When the chamber is pressurized, I understand that I must be able to equalize the pressure in my ears to avoid possible severe ear discomfort.

The most effective method to equalize ear pressure is to hold the nose, close the mouth, and blow gently through the nose.

Other methods include yawning, swallowing, and holding the nose while swallowing.

IF THE PRESSURE IN MY EARS FAILS TO EQUALIZE USING ANY OF THESE METHODS, I AGREE TO COMMUNICATE ANY DISCOMFORT TO THE ATTENDANT IMMEDIATELY.

The attendant will adjust the pressure to
attempt to alleviate the discomfort, but if the pressure in my ears cannot be equalized, the treatment will be discontinued promptly. In that event, I understand no further sessions will be scheduled for me until I have obtained a release from my physician for the therapy.

Gastrointestinal issues. I understand that HBOT may assist my body in detoxifying digestive flora.

As a result, I may experience some discomfort within the first 36 hours following the session. Symptoms may include loss of appetite, stomachache, constipation or diarrhea, headache, body aches, irritability, or other emotional upset.

I understand that although this is a normal process, if the symptoms persist
beyond 36 hours, I must consult a physician for evaluation.

Drop in blood sugar levels. Insulin-dependent diabetics may experience a drop in blood sugar while in the chamber. IF I take insulin, I understand that must test my blood sugar prior to my session; and eat a snack if my level is under 150.

I must test again when I leave the chamber; and eat a snack prior to leaving the facility if my level is under 150.

I agree to communicate to the attendant immediately if I feel uncomfortable at any time during the session.

Other side effects may include headache, nausea, drowsiness, hyperactivity, dizziness, claustrophobia, or blurred vision. 

Piercings and Jewelry will need to be removed as able. No sharp objects are allowed in the HBOT

Although Hyperbaric Therapy has been reported to be beneficial for a wide range of conditions, this therapy is not meant as a cure for any condition or disease and no therapeutic outcomes can be guaranteed.

We do not in any way recommend HBOT as a substitute for any medical treatments
prescribed or suggested by any medical physician. We do not make any guarantees to any results that an individual may experience.

We do not accept health insurance for our services. The Body Fix Coach accepts no liability for any problems that may arise from HBOT treatments.

I acknowledge that I have read the above information completely.

I have received to any questions I may have about the treatment. I am fully informed of the possible side effects and complications that may arise from the treatment. Being fully informed, I agree that I am obtaining this treatment to me, I hereby release and hold harmless Moreau Physical Therapy, its employees, agents, representatives, lessees, and assigns, from liability for any and all effects or lack
thereof, side effects, or complications that may arise as a result of the HBOT treatment.

I hereby authorise The Body Fix Coach Limited to take any further information needed for my sessions.

 

I consent to the release of information and/or disclosure of any part of my medical record by any physician, hospital, accreditation, or regulatory organisation responsible for monitoring or evaluation health facilities as well as any other facility of which I have been a client.

Please sign below confirming the accuracy of your information on this form.