Patient Portal Clinic Portal

Hyperbaric Oxygen Safety Screening

Intake Form

Yes   No

Yes   No

Checklist

High blood pressure or taking blood pressure medication*:
Yes   No
Ear or sinus disease*:
Yes   No
Lung disease, heart disease, older, sicker*:
Yes   No
Asthma*:
Yes   No
Claustrophobia*:
Yes   No
Poor Blood Sugar Control and/or Insulin-Dependent diabetic*:
Yes   No
Cataracts*:
Yes   No
Seizure disorders/epilepsy, or taking anti-seizure meds*:
Yes   No
Uncontrolled high fever*:
Yes   No
Diabetes*:
Yes   No
Congenital Spherocytosis or sickle cell anemia*:
Yes   No
Lung disease, COPD, emphysema, collapsed lung, or fluid in the lungs*:
Yes   No
History of chest surgery*:
Yes   No
Pregnancy*:
Yes   No
Cancer*:
Yes   No
Heart Failure*:
Yes   No
Do you have any implanted medical devices? This includes pacemakers, deep brain stimulation, and all other electronic medical device implants) *:
Yes   No
Have you already had any hyperbaric sessions and if so how many and when was your last session*:
Yes   No

Consent Form

Payment Detail

Description Subtotal Discount Total
Service Cost $99.00 $0.00 $99.00

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Review Details

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