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Consent For Hyperbaric Therapy
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Name
*
First
Last
IC Num (Last 4 Digits)
Questionaire Purpose
The purpose of this health questionnaire is to find out if you need a medical examination before a hyperbaric treatment.
As a safety measure, anyone suffering from the following health conditions must not use Oxynova®️ hyperbaric chambers. I fully understand and agree that i do not have the following conditions beneath:
I am aware that hyperbaric therapy represents a complementary, non-medical treatment, and does not surrogate any medical therapy. Always consult with your healthcare supervisor before starting any treatment protocol in the Oxynova®️ hyperbaric chamber . If you experience any pain or difficulty with this type of therapy, stop and consult your healthcare provider.
All problems related to the eardrum, including eardrum tearing;
Pneumothorax;
Acute nasal congestion;
Blocked eustachian tubes (ear) , Internal infection of the ear;
Upper respiratory tract infections or chronic sinusitis;
Seizure disorder;
Acute headaches or flu / cold symptoms;
Otitis or other ear related conditions;
Cough or nasal congestion .Intense fever; Intense fatigue; Headache; Intense muscular pains; Chills or hot flash
Under the influence of alcohol or recreational drugs.
Diabetes Type 1
Untreated pneumothorax
Possible adverse effects and possible complications
Ear and/or lung barotrauma (injury caused by heightened air pressure);
Temporary changes in vision;
Lightheadedness;
Fatigue;
Low blood sugar.
What is the level of your health?
Excellent (Click For Drop Down Box)
Good
Fair
Poor
Are you currently on any contraindicated drugs?
Topamax
Epival or Depakene
Citalopram or celexa
All anticonvulsants
Bleomycin
Cisplatin
Disulfiram (Antabuse)
Doxorubicin hydrochloride (Adriamycin)
Mafenide Acetate (Sulfamylon)
Claustrophobia
Claustrophobia refers to the discomfort or the feeling of being trapped in an enclosed place. It is possible that a hyperbaric chamber treatment triggers the symptoms related to claustrophobia. They can manifest in varying degrees. Nonetheless, it is very important to remain calm. If a treatment has to be stopped because the feeling of claustrophobia is too intense, one must still follow the depressurization procedure correctly.
To be done during a session:
Allow yourself some rest and indulge in a calm inducing activity such as sleeping, reading a book, meditating, or listening to your favorite music. The person inside the hyperbaric chamber can easily communicate with an attendant who is outside of the hyperbaric chamber when the latter approaches a window.
To do after the session:
After the completion of the treatment in the hyperbaric chamber, the treatment effect continues for approximately six more hours, because of the higher oxygen concentration in the user’s body. Feelings of relaxation, concentration, and greater energy as well as a pleasant feeling of tiredness can also be experienced. Effects of the treatment can be seen and felt right away or a day or two after the treatment. The number of necessary treatments may vary from one user to another depending on the reason for the consultation.
Please list your most concerning health care problems at this time (in order of importance to you)
Declaration
I declare that the information provided about my medical status is accurate and that I will inform the clinic/center or operator of any changes in my medical condition.
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Acne / Lifting Treatments
NEOGEN™ Evo Plasma Treatment
EndyMed™ 3DEEP (Radio Frequency) RF
Exosome Facial
TAC Bojin Guasha Facial
Filgora Skin Booster (NCTF 135HA)
Plasma Fibroblast Skin Tightening
Skin Treatments
Hydrafacial™
Intraceuticals™ Oxygen Facial
EndyMed™ RF
Exosome Facial
NeoGen™ Evo Plasma Facial
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Coolshaping2 Fat Freeze
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