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H
Hyperbaric
Name
*
Phone
*
Email
*
Date of Birth
Height
Weight
Occupation
How did you find our clinic? - Internet, Friend, Sign, Health professional, Other
Do you have any of the following?
Upper respiratory infection
Sinusitis
Middle ear infection
Damaged ear drum
Hearing problems
Emphysema
Tinnitus
Seizures
Collapsed lung
Pulmonary disease
Pregnant
How much water do you drink each day?
Do you sleep well?
Are you tired in the morning?
Are you tired in the afternoon?
Do you smoke?
Amount per week
Drink alcohol?
Amount per week
Do you listen to very loud music on a regular basis?
Do you have any other health issues? Please describe
Are you taking any medication or supplements? Please list
Treatment consent
The information provided is accurate to the best of my knowledge and belief. I am aware of the risks associated with this treatment and give my full consent to undergo hyperbaric oxygen therapy.
Print name
Signature
Date
Notes
Comments
This field is for validation purposes and should be left unchanged.
Name
*
Phone
*
Email
*
Date of Birth
Height
Weight
Occupation
How did you find our clinic? - Internet, Friend, Sign, Health professional, Other
Do you have any of the following?
Upper respiratory infection
Sinusitis
Middle ear infection
Damaged ear drum
Hearing problems
Emphysema
Tinnitus
Seizures
Collapsed lung
Pulmonary disease
Pregnant
How much water do you drink each day?
Do you sleep well?
Are you tired in the morning?
Are you tired in the afternoon?
Do you smoke?
Amount per week
Drink alcohol?
Amount per week
Do you listen to very loud music on a regular basis?
Do you have any other health issues? Please describe
Are you taking any medication or supplements? Please list
Treatment consent
The information provided is accurate to the best of my knowledge and belief. I am aware of the risks associated with this treatment and give my full consent to undergo hyperbaric oxygen therapy.
Print name
Signature
Date
Notes
Name
This field is for validation purposes and should be left unchanged.
