Initial Consultation Form

Hello Oxygen Friend!

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 15-20 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.

Full Name(required)

Date of Birth(required)

Email(required)

Address(required)

Phone Number(required)

Emergency Contact Full Name(required)

Emergency Contact Phone Number(required)

Emergency Contacts Relationship to you(required)

How did you hear about us?(required)

Do you have or have you ever suffered from Thrombosis or Blood Clots?(required)

Do you have or have you ever suffered from Hemorrhage(s)?(required)

Do you have or have you ever suffered from Hernia?(required)

Do you have or have you ever suffered from Varicose Veins or Phlebitis?(required)

Do you have or have you ever suffered from Skin Disease or Disorder?(required)

Do have you ever suffered from Stroke?(required)

Do you have or have you ever suffered from Tumors or Cysts?(required)

Do you have or have you ever suffered from Abdominal or Chest Complaints?(required)

Are you or could you knowingly or unknowingly be Pregnant?(required)

Do you have or have you ever suffered from Epilepsy or Seizures?(required)

Do you or have you ever suffered from a Heart Condition?(required)

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

Are you currently on or ever been on Cancer Therapy Drugs? If so, what drugs and when?(required)

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

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

Do you suffer from Grave's Disease?(required)

Are you taking any Immune Suppressants?(required)

Do you suffer from Claustrophobia?(required)

Have you ever taken the drug Bleomycin?(required)

Are you currently using Mafenide Acctate? (A topical Skin Ointment) (required)

Do you suffer from Motor Neurone Disease?(required)

Do you suffer from Heart or Lung Disease?(required)

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

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

Do you suffer from Asthma?(required)

Do you suffer from any ear issues when flying?(required)

Do you have issues breathing through your nose?(required)

– 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 – Is your home or work located within 600m of a Cellphone Tower?(required)

Is your home or work located within 600m of High Tension Power lines or Power Pylons?(required)

Do you have a Smart Meter installed in your house or work? If yes, how close to the main living area is it?(required)

Do you have a cordless Telephone or Baby Monitor at work or home?(required)

Do you have a Electrical Clock Radio in your bedroom? If yes where is located and how close to your head at night?(required)

Do you use a TV or other Electrical Entertainment in your bedroom?(required)

Do you have WIFI routers in your home or at work?(required)

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?(required)

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

General Questions:Are you currently taking any Medication? If so how much, what for and what dose?(required)

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

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? (required)

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

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

Is there any other information that you think we need to know about to get a full understanding of your current condition? If so please explain here(required)

Lastly 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 a 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.

Also, last but not lease, we have a friendly and furry four legged team member here called Caesar – a British Bulldog, but don’t let his staunch look fool you, the only thing he loves more then Hyperbaric Oxygen is cuddles and a pat! However if for any reason you do not feel comfortable with him being present, please let us know and we will make sure he takes the day off.

Thank you for taking the time to complete this form, We look forward to seeing you in our clinic soon.