Hyperbaric Medical Clearance Intake
To help our hyperbaric physicians better understand your medical history, please complete this form as thoroughly and accurately as possible. Your physician will review your responses with you during your appointment and discuss any questions or concerns.Please include all current and past medical conditions, surgeries, medications, allergies, implanted devices, hospitalizations, pregnancies, and any other relevant health information. Even details that may seem unrelated can be important when determining whether hyperbaric oxygen therapy is safe and appropriate for you.Failure to provide complete and accurate medical information may delay treatment, affect your physician's medical recommendations, or increase the risk of complications during hyperbaric oxygen therapy. Your honesty and attention to detail are essential to ensuring your safety and helping us provide the highest quality of care.Your privacy is important to us. The information you provide on this form is protected under the Health Insurance Portability and Accountability Act (HIPAA) and will be kept confidential. Your medical information will only be used for your evaluation, treatment, healthcare operations, or as otherwise permitted or required by law.
Name
*
First Name
Last Name
Date of Birth (mm/dd/yyyy)
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In your own words, please tell us why you are seeking treatment and what you are hoping to improve with HBOT.
*
Please list any diagnosis’s or conditions a medical practitioner has given you in the past (ex. anxiety, high cholesterol)
*
Are you currently pregnant or plan to become pregnant soon?
Yes
No
Approximately when was your last chest x-ray?
Have you previously undergone chemo or radiation therapy?
No
Yes
If you answered yes, please explain
Are you currently undergoing chemo or radiation therapy or will you soon be?
No
Yes
If you answered yes, please explain
Have you had or do you currently have any of the following? (Select all that apply)
Hypertension
Hypercholesterol
Micardial Infarction
Other Heart Disease
Diabetes
Coronary Artery Disease
Congestive Heart Failure
Asthma
COPD
GERD
Liver Disease
Emphysema
Pneumonia
Gastritis
Inflammatory Bowel Disease
Chron's Disease
Kidney Disease
Transient Ischemic Attack
Dementia/Alzheimers
Traumatic Brain Injury
Autism
Anoxic Brain Injury
Neuropathy
Fibromyalgia
Chronic Pain
Arthritis
Anxiety
Panic Attacks
Longhaul Covid
PTSD
Skin Disorders
Stroke
Sleep Apnea
Recent Dental Surgery
Autoimmune Disorders
Pneumothorax/Collapsed Lung
Ulcers
Optic Neuritis
Cancer
Claustrophobia
Other
Do you currently have any pain pumps, electronic or battery operated devices implanted? If yes, please explain.
Please list any past hospitalizations and/or major surgeries
*
Please list any allergies to medication
*
Current medications and dosage (prescription and supplements)
*
Alcohol Consumption: How many drinks do you consume on a daily basis?
Current or previous smoker? If yes, how many packs a day and for how long?
Currently using or history of using illicit Drugs? If yes, please explain
Have you had a family member with any of the following? If so, check all appropriate boxes.
Alcoholism
Thyroid Disease
Epilepsy
Bleeding Disorder
Heart Disease
Hypertension
Asthma
Cancer
Diabetes
Mental Disorders
If any boxes are checked, please list who in your family and if they are still living or deceased.
Is there anything else you would like to include?
Submit
Should be Empty: