Hyperbaric Health Questionnaire

Health Questions

Hyperbaric oxygen therapy

To ensure we your upcoming session is delivered safely, we require you to update us on some information about your health. This data is stored securely and you will be required to enter it before each session.

Name

Do currently have any of the following health issues?

Ears or Sinus disease/surgery/congestion (difficulty on airplanes, cold/flu)

YesNo

Infection or fever

YesNo

Claustrophobia

YesNo

High Blood Pressure or taking blood pressure medications

YesNo

Diabetes, Poor blood sugar, uncontrolled high fevers, seizures

YesNo

Collapsed lung or fluid in the lungs Lung disease, COPD, emphysema, chest surgery

YesNo

Heart Disease (CHF) or heart attack in the previous 12 months

YesNo

Congestive Heart failure

YesNo

Pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS ect

YesNo

Cataracts / Any eye disease currently being treated

YesNo

Medically being treated or on any prescribed medications

YesNo

Flown in the past 24 hours, and will not fly in the next 24 hours

YesNo

Are you pregnant?

YesNo

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I testify that the information I have provided is true and accurate to the best of my knowledge, and I have been explained the potential risks for any of the above questions that I answered “yes” to and have been given the opportunity to speak to my doctor or healthcare provider about this.

Thank you for sharing.

We look forward to seeing you for your session.

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