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HBOT Medical Declaration

Please answer the following questions on your past or present medical history with Yes or No * If you are not sure, please answer Yes *

Your Name*

Your email address if you have one*

Your phone no. (mobile preferred)*

Your date of birth (dd/mm/yyyy)*

Could you be pregnant, or are you attempting to become pregnant?

Yes/No*

-- Select --

Do you currently have a cold or high fever?

Yes/No*

-- Select --

Have you ever had or do you currently have any of the following?

Collapsed lung or fluid in the lungs, lung disease, COPD or emphysema?

Yes/No*

-- Select --

Congenital spherocytosis or Sickle Cell anaemia?

Yes/No*

-- Select --

Lung Cancer, pneumonia, pulmonary fibrosis

Yes/No*

-- Select --

Asthma

Yes/No*

-- Select --

Recent chest surgery

Yes/No*

-- Select --

Untreated hernia

Yes/No*

-- Select --

Suffered from seizure disorders or epilepsy

Yes/No*

-- Select --

High Blood Pressure or taking blood pressure medications

Yes/No*

-- Select --

Ears or Sinus disease/surgery ie Stapedectomy, congestion (difficulty on airplanes)

Yes/No*

-- Select --

Recent (within the last 12 months) perforated ear drum

Yes/No*

-- Select --

Ear grommets

Yes/No*

-- Select --

Claustrophobia

Yes/No*

-- Select --

Diabetes, low blood sugar

Yes/No*

-- Select --

Heart Disease (Congestive Heart Failure) or Ejection Fraction less than 35%

Yes/No*

-- Select --

Do you have cataracts or any other eye disease

Yes/No*

-- Select --

Do you suffer any severe allergies

Yes / No*

-- Select --

Do you have any implanted medical devices (DBS, Pacemaker, etc)

Yes/No*

-- Select --

Are you presently taking prescription medications or medically being treated? If so, please specify below:

Medications:*

Main reason for having hyperbaric therapy*

The information I have provided about my medical history is true and accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions.

Date:*

Sign Here*

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