Project Peach
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Safety Screening Form for up to 2 ata therapy

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

Please ensure you only tick ONE answer per question
Could you be pregnant, or are you attempting to become pregnant?
No
Yes
Do you currently have a cold or high fever?
No
Yes
Have you ever had, or do you currently have any of the following?
Collapsed lung or fluid in the lungs, lung disease, COPD, emphysema
No
Yes
Congenital spherocytosis or Sickle Cell anaemia
No
Yes
Lung Cancer, pneumonia, pulmonary fibrosis
No
Yes
Asthma
No
Yes
Recent chest surgery
No
Yes
Untreated hernia
No
Yes
Suffered from seizure disorders or epilepsy
No
Yes
High Blood Pressure or taking blood pressure medications
No
Yes
Ears or Sinus disease/surgery ie Stapedectomy, congestion (difficulty on airplanes) 
No
Yes
Recent (within the last 12 months) perforated ear drum
No
Yes
Ear grommets
No
Yes
Claustrophobia
No
Yes
Diabetes, low blood sugar
No
Yes
Heart Disease (Congestive Heart Failure) or Ejection Fraction less than 35%
No
Yes
Do you have cataracts or any other eye disease
No
Yes
Do you have any implanted medical devices (DBS, Pacemaker, etc)
No
Yes
Are you presently taking prescription medications or medically being treated? If so, please specify below:
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.
Click to Sign...
Submit
HBOT and light-based therapies are complementary wellness therapies and are not intended to diagnose, treat, cure, or prevent disease.

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Phone
07885 204801
Email
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Hyperbaric Health & Healing
1 Eldersley Close, Redhill, RH1 2AJ
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