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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)
*
Ears or Sinus disease/surgery/congestion (difficulty on airplanes, cold/flu)
Yes
No
Infection or fever
*
Infection or fever
Yes
No
Claustrophobia
*
Claustrophobia
Yes
No
High Blood Pressure or taking blood pressure medications
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High Blood Pressure or taking blood pressure medications
Yes
No
Diabetes, Poor blood sugar, uncontrolled high fevers, seizures
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Diabetes, Poor blood sugar, uncontrolled high fevers, seizures
Yes
No
Collapsed lung or fluid in the lungs Lung disease, COPD, emphysema, chest surgery
*
Collapsed lung or fluid in the lungs Lung disease, COPD, emphysema, chest surgery
Yes
No
Heart Disease (CHF) or heart attack in the previous 12 months
*
Heart Disease (CHF) or heart attack in the previous 12 months
Yes
No
Congestive Heart failure
*
Congestive Heart failure
Yes
No
Pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS etc
*
Pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS etc
Yes
No
Cataracts / Any eye disease currently being treated
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Cataracts / Any eye disease currently being treated
Yes
No
Medically being treated or on any prescribed medications
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Medically being treated or on any prescribed medications
Yes
No
Flown in the past 24 hours, and will not fly in the next 24 hours
*
Flown in the past 24 hours, and will not fly in the next 24 hours
Yes
No
Are you pregnant?
*
Are you pregnant?
Yes
No
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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.
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