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Hyperbaric Health Form

To ensure we your upcoming session is delivered safely, we require you to update us on some information about your health. This data is stored securely and you will be required to enter it before each session.

Full name

Email

How did you hear about us?

Ears or Sinus disease/surgery/congestion (difficulty on airplanes, cold/flu)

Yes

Infection or fever

Yes

Claustrophobia

Yes

High Blood Pressure or taking blood pressure medications

Yes

Diabetes, Poor blood sugar, uncontrolled high fevers, seizures

Yes

Collapsed lung or fluid in the lungs Lung disease, COPD, emphysema, chest surgery

Yes

Heart Disease (CHF) or heart attack in the previous 12 months

Yes

Congestive Heart failure

Yes

Pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS etc

Yes

Cataracts / Any eye disease currently being treated

Yes

Medically being treated or on any prescribed medications

Yes

Flown in the past 24 hours, and will not fly in the next 24 hours

Yes

Are you pregnant?

Yes

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I testify that the information I have provided is true and accurate to the best of my knowledge, and I have been explained the potential risks for any of the above questions that I answered “yes” to and have been given the opportunity to speak to my doctor or healthcare provider about this.

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I'd like to receive discounts, benefits and news about health technology from Until. You can change the way we contact you or unsubscribe at any time.