• HBOT Client Intake Form

  • How did you hear about Aureum Wellness

  • Sex?*
  • Date of Birth
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    2 digit day, 2 digit month, 4 digit year
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  • Have you done mild Hyperbaric Oxygen Therapy or Red Light Therapy before?
  • Did you have an adverse reaction
  • Primary reason for seeking mild Hyperbaric Oxygen Therapy (mHBOT) and/or Red Light Therapy (RLT)

  • The purpose of the following questions are not to diagnose any medical condition but rather to get a measurable sense of your current health and symptoms in order to measure improvement.

    On a scale of 0-10 (0 = none; 10=extreme) please rate any of the following symptoms you may have experienced over the last 2 weeks.

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  • Main Goal for the next 8-12 weeks

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  • Are you currently taking any medications or supplements?*
  • Do you have ear or sinus issues (e.g. chronic ear infections, recent ear surgery, severe sinusitis)?*
  • Have you ever been told you have Cataracts?*
  • Do you have any current or past lung conditions, such as pneumothorax/collapsed lung, COPD, emphasyma, severe asthma?*
  • Are you pregnant or think you might be?*
  • Do you have any heart conditions? (e.g. congestive heart failure, uncontrolled high blood pressure).*
  • Do you have a history of seizures or epilepsy?*
  • Are you currently undergoing chemotherapy or taking medications such as bleomycin or disulfiram?*
  • Do you have any implanted medical devices (e.g. pacemaker, insulin pump)?*
  • Do you suffer from claustrophobia or anxiety in confined spaces?*
  • Do you have any recent injuries or surgeries, especially involving the chest, brain or ears.*

  • To ensure the best experience with mHBOT, if, at the time of your appointment, or the 7 days prior to your appointment, you have had a cold/flu or other respiratory or sinus condition, we recommend you delay your appointment until fully recovered.

  • Disclaimer: Red Light Therapy (RLT) and Mild Hyperbaric Oxygen Therapy (mHBOT} may not be safe for everyone.  By signing below, you confirm that your answers are accurate and you understand that you should consult a healthcare provider before using RLT and mHBOT.  Aureum Wellness is not a medical professional and assumes no liability for any adverse effects.

    Red Light Therapy and Mild Hyperbaric Oxygen Therapy (mHBOT) are offered as a wellness tool, not a medical treatment.  Aureum Wellness is not a healthcare provider and does not diagnose, treat, or cure any medical conditions.  By using the RLT bed and/or mHBOT chamber, you acknowledge:

    1. Health Risks:  mHBOT may carry risks, including, but not limited to, ear barotrauma, oxygen toxicity, claustrophobia, or temporary vision changes.  Not all risks are known.

    2. Ear-Related Considerations and Tympanostomy Tubes (Grommets/Ear Ventilation Tubes): Hyperbaric oxygen therapy (HBOT), even at mild pressures such as 2.0 ATA, involves changes in ambient pressure that require the middle ear to equalize effectively to avoid barotrauma (pressure-related ear injury), which is the most common side effect of HBOT and may cause temporary pain, fullness, or fluid buildup. Clients with pre-existing tympanostomy tubes (also known as ear grommets or ventilation tubes) are often able to tolerate treatment well, as these tubes can facilitate passive pressure equalization and reduce the risk of barotrauma compared to those with untreated eustachian tube dysfunction. However, the presence of tubes may increase the potential for complications such as ear discharge (otorrhea), infection, or persistent perforation in some cases, particularly if tubes are not patent or if there is any active ear issue. All clients disclosing ear grommets must provide clearance from an ENT specialist or qualified healthcare provider confirming the tubes are functional and suitable for HBOT. We will monitor closely during sessions, recommend dry ear precautions (e.g., avoiding water exposure), and pause treatment if any ear symptoms arise. Immediate medical attention is required for signs of infection, severe pain, or discharge.

    3. Medical Clearance: You are responsible for consulting a healthcare provider to confirm if RLT and mHBOT are safe for you, especially if you have conditions like lung issues, pregnancy, seizures, or take certain medications.
    4. Voluntary participation: Your use of the chamber is voluntary.  You assume all risks associated with the mHBOT.
    5. No Liability: The chamber owner (Alexandra Hughes, Aureum Wellness) is not liable for any injury, discomfort or adverse effects resulting from RLT or mHBOT use, whether known or unknown.
    6. Accurate information: You confirm that all health information provided in the screening form is accurate and complete.
    7. By signing below you agree to these terms and confirm you have consulted a healthcare provider as necessary.

  • Patient acknowledges and agrees that practitioner (Alexandra Hughes, Barry Hughes) and Aureum Wellness, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to Aureum Wellness.

  • Today's Date*
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  • Today's Date*
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