Richmond Hyperbaric Health Center  

MEDICAL HISTORY  FORM  Primary Diagnosis: _______________________________________________________________ Secondary Diagnosis: _______________________________________________________________ Have you ever had or are you taking medication for any of the following  (Yes or No): _____ Previous hyperbaric oxygen therapy                  ______ Hay fever (frequent or severe) _____ Stroke  ______ Frequent colds or sinus condition _____ Cancer _______ Any form of lung condition _____ Rheumatic condition _______ Chest surgery _____ Claustrophobia _______ Epilepsy, seizures, convulsions _____ Recurring migraine headaches _______ Blackouts or fainting (full/partial) _____ Decompression sickness _______ Diabetes ______ High Blood Pressure _______ Prostheses (e.g. limbs, tooth) ______ Heart / Angina condition _______ Angina pectoris (Heart pain)     _____ Dentures (removable) _______ Blood vessel surgery _____ Asthma or wheezing with breathing _______ Ear surgery _____ Hearing Loss _______ Problems with balance ______ Problems equalizing (popping) Ears _______ Bleeding or other blood disorders _____ Ulcers   _______ Colostomy _____ Drug abuse (e.g. Alcohol) ______ Smoking (e.g. tobacco) If female, is there a possibility that you may be pregnant?____________________________ ________________________________________________________________________ Do you have any allergies (e.g. Latex/ Meds)?_____________________________________ Have you smoked in the last 6 months?__________________________________________ Date & result of latest chest X-ray?_____________________________________________ Are you now receiving any other forms of therapy?_________________________________ Please elaborate on any positive response (Medications/ Surgeries): _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ A positive response to any of the above conditions means that there is a pre-existing condition that may affect your safety in receiving hyperbaric oxygen therapy.  Such a condition does not necessarily disqualify you from receiving therapy when appropriate means are in place. The point of the checklist is to ensure that you are physically able to receive hyperbaric oxygen therapy in a hyperbaric chamber. Should you have any doubts about your present physical condition, you may wish to consult with your physician. The information I have provided about my medical history is accurate to the best of my knowledge. ____________________________________          ______________________                            Signature                                                      Date ________________________________________                _________________________               Print name and relationship to client                                  Date