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 before and during your appointment and discuss any questions or concerns. 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
In your own words, please tell us why you are seeking treatment and what you are hoping to improve with HBOT.
*
Please answer "Yes" or "No" to the following questions. If you answer "yes", our hyperbaric physician will discuss more during your appointment.
Have you ever had a collapsed lung (pneumothorax) that has not been treated or is currently present?
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Yes
No
Have you ever been treated with a medication called bleomycin (a type of chemotherapy)?
*
Yes
No
Have you ever or are you currently taking cisplatin, doxorubicin, disulfiram, mafenide/sulfamylon?
*
Have you previously undergone any other chemo or radiation therapy?
*
Yes
No
I plan to in the near future
Do you have COPD, emphysema, or another long-term lung condition?
*
Yes
No
Do you have asthma or a condition that causes wheezing or trouble breathing?
*
Yes
No
Have you ever had surgery on your chest/lungs?
*
Yes
No
Do you currently have a cough, cold, chest infection, bronchitis, or other breathing illness?
*
Yes
No
Do you use oxygen at home or need oxygen to help you breathe?
*
Yes
No
Do you currently have a cough, cold, chest infection, bronchitis, or other breathing illness?
*
Yes
No
If yes, please let us know when and what the results were.
Pulmonary
Have you ever had trouble “popping” or equalizing the pressure in your ears, especially during airplane flights or diving?
*
Yes
No
Have you ever had ear surgery, ear tubes, a hole in your eardrum, or other major ear problems?
*
Yes
No
Do you frequently have sinus problems, nasal congestion, or blocked ears?
*
Yes
No
Have you been told that you may need to see an ENT (Ear, nose and throat doctor)?
*
Yes
No
Do you have Congestive heart failure or Heart Disease?
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Yes
No
Do you have high blood pressure that is currently uncontrolled or difficult to manage?
*
Yes
No
Do you have coronary artery disease, a heart rhythm problem, or an irregular heartbeat
*
Yes
No
Do you have a pacemaker, defibrillator (ICD), or another implanted medical device?
Yes
No
Have you had an EKG/ECG (heart tracing) recently?
*
Yes
No
Have you ever had a seizure or been diagnosed with epilepsy
*
Yes
No
Have you ever had a serious head injury, brain surgery, or a leak of fluid around the brain/spinal cord?
*
Yes
No
Have you recently had an injury or surgery involving your head or brain?
*
Yes
No
Have you had recent eye surgery or treatment for a serious eye condition?
*
Yes
No
Do you have cataracts, retinal problems, optic neuritis, or another significant eye condition?
*
Yes
No
Do you understand that your vision may temporarily become slightly more nearsighted after a series of hyperbaric treatments?
*
Yes
No
Please discuss this more
Do you have diabetes?
*
Type l
Type II
I do not have diabetes
If you have diabetes, do you monitor your glucose?
*
Yes
No
I wear a continuous glucose monitor
Have you ever had problems with low blood sugar?
*
Yes
No
Do you currently have a fever or active infection?
*
Yes
No
Have you ever been told you have a blood condition called hereditary spherocytosis?
*
Yes
No
Do you have claustrophobia (fear of enclosed spaces) or severe anxiety in small spaces?
*
Yes
No
Are you currently pregnant, possibly pregnant, or trying to become pregnant?
*
Yes
No
Not applicable
Please any prescriptions, over-the-counter medications, vitamins, and supplements.
*
If you would like to upload your medication list, you can do so here
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Do you use an insulin pump, medication patch, hearing aid, or other device that may need to be removed before treatment?
*
Do you currently have any pain pumps, electronic or battery operated devices implanted? If yes, please explain.
*
Have you had recent dental surgery or a recent tooth extraction?
*
Yes
No
Do you currently have significant dental pain, an untreated dental problem, or recent dental work?
*
Yes
No
Please list any diagnosis’s or conditions a medical practitioner has given you in the past (ex. anxiety, high cholesterol, hypertension, diabetes)
*
Please list any past hospitalizations and/or major surgeries
*
Please list any allergies to medication
*
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.
If there are any medical records you would like our hyperbaric physician to see, please uoload here.
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