Initial consultation form.

To help us create the best possible plan for your treatment, please answer the following questions as fully as possible. If any answer is “YES” please provide more information including when it occurred, severity level, any medication, dose and how long you have been taking it for.

Please allow 10 minutes to fill out the form below and ensure you have completed this a minimum of 24 hours before your session with us. If you are unable to complete this form for any reason please give us a call on 0272357100 to discuss. Failure to complete this form will result in your session being cancelled and you will be charged 100% of the session cost.

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Name

Date of birth (DD/MM/YYYY)

Phone

Address

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

SPECIFIC HEALTH QUESTIONS:

Are you pregnant?

Have Epilepsy?

Suffered from a seizure?

Used the skin topical ointment Mafenide Acetate?

Taken the cancer drugs Bleomycin, Cisplatinum, Doxorubicin, Disulphiram?

Taking Immune Suppressants?

Do you have or have you ever suffered from Epilepsy or Seizures?

Do you have or have you ever suffered from a Heart Condition?

Is your blood pressure high, normal, low or not sure? Do you take any medication for blood pressure?

Do you have any Electrical Implants such as Pacemaker, Defibrillator, Cochlear Implant etc.?

Do you suffer from either Hypothyroidism (underactive) or Hyperthyroidism (overactive)?

Do you suffer from Grave's Disease?

Do you suffer from Claustrophobia?

Do you suffer from Motor Neurone Disease?

Do you suffer from COPD? (Chronic Obstructive Pulmonary Disorder)

Do you have a history of Pneumothorax / Collapsed lung(s)?

Do you suffer from Asthma?

Do you suffer from any ear issues when flying?

Do you have issues breathing through your nose?

ENVIRONMENTAL CONSIDERATIONS: Please answer YES or NO to the following questions, if you answer yes please tell us a little more about your work or home premises and your daily living association to EMF (ElectroMagnetic Field) transmissions.

Do you take your phone into your bedroom at night? If so where do you keep it? Do you turn any functionality off or on, if so what? E.g. WIFI, airplane mode etc. Do you charge your phone will you are sleeping?

Do you use any EMF protective solutions in your day to day life?

GENERAL QUESTIONS:

Are you currently taking any Medication? If so how much, what for and what dose?

Do you have any reactions, allergies or sensitivities? If so what are they?

Have you ever had any other medical diagnosis that we haven't already been made aware of in previous questions? If so, what? When were you diagnosed and what is the severity?

Are you working with any other Health Care practitioners currently? If so, who and what are you doing?

What are you hoping to get out of the treatment with us?

Is there any other information that you think we need to know about to get a full understanding of your current condition?

To optimize your experience there are a few things we would like to share:

As we do not have a shower on our premises please ensure that you are showered and fresh, wearing comfortable clothes to your session. Parking is located outside the front windows of our building please feel free to park there.

Please note: 48 hour notice must be given to transfer the session to another date. Alternatively, any less then 48 hours notice will incur a charge of 50% of the total session cost and any less then 24 hours will be charged at 100% of the total session cost.

Thank you for taking the time to complete this form.
We look forward to seeing you.

Hyperbaric Oxygen Therapy Christchurch