Hyperbaric Oxygen Therapy Intake Form
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Hyperbaric Oxygen Therapy Intake Form
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This hyperbaric oxygen therapy intake form provides a thorough evaluation protocol for facilities offering HBOT treatments. The form systematically screens for critical contraindications including untreated pneumothorax, certain medications, claustrophobia, and upper respiratory infections that could compromise treatment safety. It documents the primary indication for therapy whether wound healing, radiation injury, carbon monoxide poisoning, decompression sickness, or other approved conditions.
The template captures detailed diving history for decompression cases, wound measurements and characteristics for healing protocols, previous HBOT experience, and ear pressure equalization ability. It includes comprehensive medical screening for pulmonary conditions, seizure disorders, cardiac history, and current medications that may interact with high-pressure oxygen environments. The form ensures proper documentation of informed consent, emergency contacts, and baseline vital signs required before initiating treatment protocols.
What's included
- Primary indication for HBOT treatment
- Contraindication screening checklist
- Diving and decompression history
- Wound measurements and characteristics
- Pulmonary and cardiac medical history
- Claustrophobia and anxiety screening
- Ear pressure equalization assessment
- Current medications and supplements
- Previous HBOT treatment history
- Chamber safety acknowledgment
Who uses this template
- Hyperbaric Oxygen Therapy Centers
- Wound Care Clinics
- Diving Medicine Practices
- Hospital-Based HBOT Units
- Integrated Wound Healing Centers
All form fields
8 fields across 3 pages. Customize any field after signing up.
How to use the Hyperbaric Oxygen Therapy Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Hyperbaric Oxygen Therapy Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Hyperbaric Oxygen Therapy Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Hyperbaric Oxygen Therapy Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Hyperbaric Oxygen Therapy Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Hyperbaric Oxygen Therapy Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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