• Hyperbaric Chamber Intake and Safety Screening Form

    Please fill out all required fields to help us assess your suitability for hyperbaric therapy.

  • Contact Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Pressure, Ear, and Sinus Screening

  • Do you have trouble with pressure changes when flying in an airplane or driving in the mountains?*
  • Do you have difficulty clearing your ears?*
  • Do you currently have ear pain, ear pressure, an ear infection, or a recent ear injury?*
  • Have you had recent ear surgery?*
  • Do you currently have sinus congestion, a cold, sinus infection, fever, or upper respiratory illness?*

  • Lung and Breathing Screening

  • Do you have any lung issues or breathing problems?*
  • Have you ever had a collapsed lung (pneumothorax)?*
  • Have you ever been told you have COPD, emphysema, asthma, pulmonary fibrosis, lung blebs, bullae, or another chronic lung condition?*
  • Have you had recent chest surgery, lung injury, pneumonia, or rib injury?*

  • Additional Safety Screening

  • Have you ever had a seizure disorder or an unexplained seizure?*
  • Are you pregnant or could you be pregnant?*
  • Do you have any implanted or attached medical devices we should know about?*
  • Do you have claustrophobia or significant anxiety in enclosed spaces?*
  • Do you have diabetes or blood sugar issues that may require monitoring?*
  • Have you recently received bleomycin, doxorubicin, or similar cancer treatments that could affect oxygen therapy or lung safety?*
  • Are you taking any prescription medications or receiving current medical treatment we should know about before scheduling?*

  • Previous Hyperbaric Experience

  • Have you used a hyperbaric chamber before?*
  • If yes, did you have any problems during or after treatment?*
  • Should be Empty: