HBOT Evaluation for treatment Name * First Name Last Name Birthdate * Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Absolute & Possible Contraindications* to HBO * Please check the box if you have had any of the following: Pneumothorx (collection of air between lung and chest wall causing reduced lung capacity and difficulty breathing). Retina surgery that includes injecting a bubble of gas into the eye. I am or there is a possibility that I am pregnant Lung biopsy or procedure requiring access into lung by penetrating thoracic wall, front or back. Congestive heart failure Emphysema with CO2 retention (COPD) History of thoracic or ear surgery Upper respiratory infections, mid-ear or chronic sinusitis Uncontrolled high fever Implant devices: will need to obtain manufacturer approval for use in the chamber Asymptomatic pulmonary lesions seen on chest x-ray Congenital spherocytosis: genetic disorder of the Red Blood Cell Membrane Sickle cell anemia None of the above Are you receiving any of the following Chemo-related drugs? * Please check the box if you are receiving any of the following: Doxorubicin - postone HBO for one week after its use Cis Platinum- slows wound healing when used during HBO Disulfiram - blocks superoxide dismutase production Mafenide acetate (sulfamylon) - promotes CO2 buildup with vasoconstricting mechanism of HBO. Bleomycin - pretreatment pulmonary function testing with carbon monoxide capacity Have you ever had radiation therapy? None of the above Common conditions to give special attention to while using HBO * Please check the box if you any of the conditions apply: Diabetes type 1 Diabetes type 2 Taking blood sugar medication Taking blood pressure medication Hypoglycemic (low blood sugar) HBO triggers increased blood sugar consumption Seizure activity? Taking anti-seizure medication Cataracts Have you ever had any ear problems? Do you have any problems with your ears when you fly? None of the above How did you hear about us? * What are your reasons for seeking hyperbaric oxygen therapy? * Are you currently undergoing medical treatment? Please describe. * If you exercise on a regular basis, how frequently? * If you use tobacco, how frequently? * If you use alcohol, how frequently? * Have you had or do you currently have any of the following? * Acute Respiratory Illness Allergies Anemia Angina/Chest Pain Anxiety Arthritis Aspergers/Autism Asthma Back Pain Balance Problems Bells Palsy Cancer or Malignant Tumor Cataracts Cerebral Palsy Chemical sensitivity Chemotherapy Chronic Back Problems Chronic Bronchitis Chronic Fatigue Claustrophobia or Panic Attacks Congenital Spherocytosis Crohns Disease COPD/Lung Disease Dementia Diabetes Type 1 or Type 2 Dizziness Ear Infections (frequent) Ear Trauma Emphysema Epilepsy or Seizure Disorder Exposed Bone Fainting Fever – current Fibromyalgia Glaucoma Headache Heart Attack Heart Disease/Heart Problems Heart Failure Heart Murmur Hepatitis/Jaundice Herpes High Blood Pressure HIV Infection/AIDS Infections (frequent) Insomnia Irritable Bowel Syndrome Kidney Disease Leukemia Liver Disease Low Blood Pressure Lung Infections (frequent) Lyme Disease Migraines Mitral Valve Prolapse MRSA (Staphylococcus) Multiple Sclerosis Neurological Disease Optic Neuritis Parkinson’s Pneumothorax/Collapsed Lung Pulmonary Cysts or Abscesses Radiation Therapy Recent Dental Surgery Recent Weight Loss/Gain Rheumatoid Arthritis Ringing in the Ears Rosacea Sinusitis Sleep Apnea Stomach Problems/Ulcers Stroke Swollen Ankles Thyroid Problems Transient Ischemic Attacks Traumatic Brain Injury Tuberculosis Upper Respiratory Infection Viral Infection – current None of the Above Please list all prescription and over-the- counter medications you are currently taking. * Have you been hospitalized for any serious illnesses within the last 5 years? * Thank you!