New Patient Forms Please enable JavaScript in your browser to complete this form. - Step 1 of 3HBOT Patient Intake FormToday's Date *PERSONAL INFORMATIONPatients Name *Date of Birth *Age *Sex (M or F) *Parents Name (if applicable)Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Business Phone *Email *Marital Status *MinorSingleMarriedSeparatedDivorcedWidowedEmployment *Full TimePart TimeUnemployedDisabledRetiredEMERGENCY CONTACTName *Daytime Phone *Relationship To Patient *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeREFERRALHow did you hear about our facility? *Friend/FamilyOnlineOtherWho can we thank for your referral? *Email *Phone *CURRENT HEALTH CONCERNSConcerns/Previous Treatment (please list in order of priority) *#2#3PHYSICIANAre you currently under the care of a physician or other provider? *YesNoDid they recommend Hyperbaric Oxygen Therapy? *YesNoDo you have a prescription for Hyperbaric Oxygen Therapy? *YesNoPhysician/Provider Name *Specialty *Physician/Provider Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysician/Provider Phone *FaxSOCIAL HISTORYTobacco Use *NeverPreviously, But QuitCurrentlyIf yes, #/DayCaffeine Use *NeverYesIf yes, frequency and source or caffeineAlcohol Use *NeverRarelyModeratelyDailyDrug Use *NeverYesIf yes, list frequency and type of drug1. CURRENT MEDICATIONS (list all medicines you are currently taking including prescription and over the counter) Medicine *MedicineMedicineDosage *DosageDosageFrequency *FrequencyFrequency2. ALLERGIES (please list all known allergies) 2. ALLERGIES (please list all known allergies) *3. DIABETES Do you have diabetes? *YesNoIf yes, do you have an insulin pump?YesNoIf yes, it will need to be removed during the session. If yes, do you takeInsulinOral AgentsDiet ControlledIf yes, how often do you test your blood sugar?4. PULMONARY LUNG DIAGNOSIS Have you ever been diagnosed with a lung/pulmonary condition or pulmonary fibrosis? *YesNoIf yes, what is the condition?5. SEIZURE OR CONVULSION ACTIVITY Have you ever experienced seizures or convulsions? *YesNoHave you ever been told you are at risk for seizures? *YesNoIf yes, what is the condition?6. EAR HISTORY Have you ever had ear problems? *YesNoDo you have an problem with your ears when you fly? *YesNoHistory of surgery/damage to your tympanic membrane? *YesNoDo you or have your ever done scuba diving? *YesNoDo you know how to equalize pressure in your ears? *YesNo7. MEDICAL IMPLANTS Do you have any implanted medical devices? *YesNoIf yes, please describe the device, manufacture date implanted.Is your medical device rated for pressure?YesNoIf unsure, you will need to verify this with the manufacturer prior to treatment. We will then need to confirm with manufacturer. 8. NUTRITION PROFILE A. Do you have difficulty chewing or swallowing? *YesNoB. Have you had a large weight loss or weight gain? *YesNoCurrent Weight *If yes, how many pounds?If yes, reason if known and current weight.C. Do you have a special diet? *YesNoIf yes, explain.D. Do you have any food allergies or sensitivities? *YesNoIf yes, explain.E. Are you involved in a weight loss program? *YesNoIf yes, explain.F. How is your appetite? *GoodFairPoorG. How much water do you drink each day? *H. Do you exercise regularly? *YesNoI. Do you take vitamins or supplements? *YesNoIf yes, list all vitamins and/or supplements taken Vitamin/SupplementVitamin/SupplementVitamin/SupplementDosageDosageDosageFrequencyFrequencyFrequency NextHBOT Consent FormThe technology known as Hyperbaric Oxygen Therapy has been reported to have beneficial effects for a wide range of conditions, without negative side effects. Nevertheless, as with many treatments there are areas of concern of which you should be aware. DO NOT CONTINUE IF: You are currently prescribed or taking the following medications Bleomycin, Disulfiram, Mafenide Acetate You have or suspect having: Hereditary Spherocytosis, Sickle Cell Anemia, COPD It is important that you take a few minutes to read the following information: OTIC BAROTRAUMA: This is a condition of injury to the eardrum and is extremely unlikely to occur in the Hyperbaric chamber. However, severe ear discomfort can be caused if you cannot equalize the pressure in your ears. As the chamber is pressurized and depressurized, you must be able to equalize the pressure in your ears to acclimate to the pressure changes. You will most likely experience “popping” in your ears. This is normal. You can assist the equalization process by yawning, chewing, swallowing, working your jaw side to side and up and down, turning the head side to side and ear to shoulder. Sitting upright in the chamber during pressurization and depressurization will generally also make the equalization process more comfortable. In general, doing whatever assists you in being comfortable when taking off and landing in an airplane may be most effective for you. Continue to do this as needed for the duration of the pressurization and depressurization. There should be no additional pressure in the ears when the chamber reaches full pressure and again when the chamber is completely deflated. EAR SINUS AND/OR THROAT CONGESTION, HEAD COLDS, VIRUS, OR PRIOR TRAUMA TO EARS: If you are suffering from any of these conditions we recommend rescheduling your visit in the chamber, Discomfort from these conditions is common. IF YOU ARE UNABLE TO EQUALIZE EAR PRESSURE AND EXPERIENCE PAIN IN ONE OR BOTH EARS, IT IS CRITICAL THAT YOU COMMUNICATE ANY DISCOMFORT IMMEDIATELY TO THE STAFF. This will give us the opportunity to adjust the pressurization or depressurization process to eliminate discomfort. If you are unable to equalize the pressure in your ears, we can either proceed very slowly with the pressurization, or the visit can be terminated. If this happens or if pain persists beyond 2 hours of the visit we recommend that you consult your physician to evaluate and alleviate the situation before attempting another visit. If the decision is made to continue treatment even when you have congestion, it may take up to 24 hours for lingering sinus pressure or discomfort to dissipate. PULMONARY HYPEREXPANSION: This condition is very rare under hyperbaric treatments. However, to be overly cautions, DO NOT HOLD YOUR BREATH DURING DECOMPRESSION as it could lead to an expansion of the air in your lungs and cause damage to the lung tissues. In the highly unlikely event of an unexpected rapid decompression, it is important that you continue to breath normally. MEDICATIONS: Hyperbaric Therapy may enhance the effectiveness or increase the metabolism (decrease the effectiveness) of medications you are taking. IT IS RECOMMENDED THAT YOU HAVE THE DOSAGE AND FREQUENCY OF ALL MEDICATIONS MONITORED AND ADJUSTED REGULARLY BY YOUR PHYSICIAN. PREGNANCY: Out of an abundance of caution we do not preform HYPERBARIC OXYGEN THERAPY during pregnancy. SEIZURES: Hyperbaric Therapy is not associated with causing or inducing seizures, but IF ANYONE GETTING IN THE CHAMBER IS SEIZURE PRONE THE STAFF MUST BE MADE AWARE PRIOR TO THE FIRST VISIT. If a seizure is experienced in our clinic, unless otherwise instructed (and a waiver is signed) our procedure is to call 911, remove the patient from the chamber and make the individual as comfortable as possible. DETOXIFYING OR CELL DIE OFF: Hyperbaric Therapy may assist the body to naturally detoxify and balance digestive flora. AN INDIVIDUAL MAY EXPERIENCE SOME DISCOMFORT FROM THIS PROCESS IN AS LITTLE AS 1 TO 36 HOURS AFTER TREATMENT. Symptoms may include flu like symptoms, loss of appetite, stomachache, constipation, diarrhea, headache, minor behavioral issues, etc. Although unpleasant, this is a natural process and continuing treatments may be of benefit to accomplish a positive result more rapidly. However, IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN TO EVALUATE AND ALLEVIATE THE SITUATION BEFORE ATTEMPTING ANOTHER VISIT. PNEUMOTHORAX: Hyperbaric Therapy is contraindicated for an existing pneumothorax (collapsed lung).IF YOU HAVE A PNEUMOTHORAX OR SUSPECT A PNEUMOTHORAX IS AN ISSUE, YOU WILL NOT BE ALLOWED IN THE CHAMBER UNTIL YOU/WE RECEIVE A DOCTORS CLEARANCE. If you have experienced a pneumothorax in the past and have already been “cleared by your doctor” to resume normal activity, once you have provided a written confirmation, you should be able to proceed with Hyperbaric Therapy. COMPRESSIVE BRAIN LESIONS – SUBDURAL HEMATOMA, INTERCRANIAL HEMATOMA: Hyperbaric Therapy is contraindicated for existing compressive brain lesions (subdural hematoma, intercranial hematoma). IF YOU HAVE COMPRESSIVE BRAIN LESIONS OR SUSPECT YOU HAVE A COMPRESSIVE BRAIN LESIONS, YOU WILL NOT BE ALLOWED IN THE CHAMBER. If you have experienced compressive brain lesions in the past and have already been “cleared by your doctor” to resume normal activity, you should be able to proceed with Hyperbaric Therapy. DIABETES / INSULIN DEPENDENT: Insulin dependency may result in a drop in blood sugar while in the chamber. IT IS CRITICAL THAT YOU IMMEDIATELY COMMUNICATE WITH THE STAFF IF YOU EXPERIENCE OR ANTICIPATE AN EPISODE. YOUR TREATMENT WILL BE TERMINATED. SENSITIVITY TO CHEMICALS (MCS) / ODORS/ ALLERGY: Avoid wearing heavy colognes as the smell may linger in the chamber and have an adverse effect on another patient. IF YOU EXPERIENCE ADVERSE SENSITIVITY OR HAVE ALLERGIES THAT MAY BECOME AGGRAVATED WHILE IN THE CHAMBER, LET THE STAFF KNOW PRIOR TO YOUR VISIT OR AS SOON AS POSSIBLE WHEN IN THE CHAMBER SO MEASURES CAN BE TAKEN TO ASSURE YOUR COMFORT OR IF YOUR VISIT NEEDS TO BE TERMINATED. We reserve the right to refuse treatment at any visit due to strong odors detected on the client. I have read and fully understand the above information. Digital Signature *Date *NextHBOT Patient EducationPatient Name *Start Date *Date of Birth *This is to provide basic instruction with regard to Hyperbaric Oxygen Therapy. I. Hyperbaric Oxygen Therapy (HBOT) Definition: High dose, 90 – 100% oxygen breathing while exposed to increased atmospheric pressure. Hyperbaric chamber – where pressure is created. Increased air pressure surrounds the patient; the patient will feel pressure in their ears and need to clear it. Similarities to flying in an airplane and scuba diving, HBOT pressure simulates these environments. Purpose: To enhance the oxygen levels in affected tissues so that normal healing mechanisms can take place at a greater pace. This helps to reduce inflammation, improve cellular energy, improve immune response, improve healing response, and increase stem release. Staff: The staff members are part of a team, specifically trained to provide this type of therapy to patients. The overseeing physician directs the patient’s hyperbaric care. The staff will assist and attend to any of the patients’ needs regarding hyperbaric oxygen therapy. II. What to Expect? Preparation: Dress comfortably & light, most people prefer short sleeve shirt and shorts We will give you an oxygen mask for your first visit, bring the mask with you for all future sessions. BYOB Bring Your Own Blanket. Many people will take a nap during their session. The temperature depends on several factors – sometimes warm, other times cool. The temperature will increase during the session. B. Pressurization or ‘Descent’ This is the part of the treatment when pressure is increased in the hyperbaric chamber. There will be a technician checking on you during the descent. During this time, you must clear your ears, early and often. It is easier to clear your ears before you feel much pressure. If you wait to clear your ears until after you are feeling significant pressure, it will be notably harder to clear your ears. The pressure change is not felt anywhere else on the body. C. At Depth: You should just lay, relax and breathe normally. Many people will take a nap or read a book, or be on phone. For extended treatments, you may be asked to take an air break, removing the mask to breathe regular air. There will be a technician checking on you during the treatment. D. Ascent or Depressurization: During this part of the treatment, pressure is removed from the hyperbaric chamber. There will be a technician checking on you during ascent. You should rest comfortably and breathe normally during ascent; clearing of the ears is not necessary. III. Equalizing The Ears Although the pressure changes in the chamber are not felt on the body, they are felt in the ears. As the pressure increases, the eardrum will try to bow inwards. To avoid this, it is important to learn how to equalize the middle ear. Hold your nose and swallow. Another way to equalize is by yawning or swallowing. You can also try opening your mouth and moving your jaw from side to side. You should not have any pain in your ears. If you begin to have discomfort, please let the technician know as they can control the rate of pressurization, pause, or lower the pressure, until you equalize. IV. Safety The chamber is very safe. We utilize high-quality mono-place chambers for individualized treatment. We uphold the highest training, safety, maintenance, and service protocols available. In addition, treatments are performed by trained technicians under the guidance of a physician. You play an active role in your own safety while in the chamber. Safety is assured by you not bringing an unsafe item in the chamber. The following is a list of materials or items which are NOT allowed in the chamber: Perfume and colognes Smoking materials or lighter Lotions or sprays V. Effects of Smoking on Healing Smoking and exposure to secondhand smoke are not recommended during the weeks you are being treated. Nicotine in cigarettes causes blood vessels to constrict, decreasing blood flow to the tissues. Smoke and tar decrease lung function, so less oxygen is absorbed by the lungs and transferred into the blood. If you do smoke, it is strongly recommended that you not smoke 2 hours before and 2 hours after hyperbaric oxygen therapy so that maximum benefits are achieved. VI. Alcohol consumption during treatments Ingestion of alcohol is not recommended during the weeks you are being treated as it can interfere with the healing process. VII. Report Cold or Flu-like Symptoms Let the staff know before your treatment, and a decision will be made whether the patient should be treated or not. We recommend delaying treatment by a day or more so that viral and congestion symptoms subside. If the decision is made to continue treatment even when you have congestion, it may take up to 24 hours for lingering sinus pressure or discomfort to dissipate. VIII. Diabetic Patients It is important to monitor blood sugars and to report any symptoms of low blood sugar immediately. Do not hesitate to let us know if you are having trouble managing your diabetes and we will assist you where we can. IX. Family Members and Visitors Family members and visitors are welcome to tour the facility and ask questions at appropriate times. For the safety and privacy of all patients, family members and visitors are asked to use the front waiting room while treatments are taking place, unless otherwise directed by the technician. X. Consistency and Commitment To achieve optimal outcome, it is important to maintain consistency and commitment with the hyperbaric oxygen therapy protocol as recommended by the hyperbaric physician. Any noncompliance on the patient’s part will be handled through the Financial Policy and could lead to rescheduling or cancellation. Digital Signature *Date *Submit