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Hyperbaric Oxygen Therapy Intake Form
Intake

Hyperbaric Oxygen Therapy Intake Form

3 pages•18 fields•HIPAA-ready
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Hyperbaric Oxygen Therapy Intake Form

Hyperbaric Oxygen Therapy Intake Form

Page 1 of 3

Patient Name
Jane Martinez
Date of Birth
03/15/1985
Primary Indication for HBOT
Select an option...
Phone Number
(555) 867-5309
Emergency Contact
Contact person
Current Medications
Known Allergies
Diving History (if applicable)
Enter details here...
Submit
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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.

Patient NameText
Date of BirthDate
Primary Indication for HBOTDropdown
Phone NumberPhone
Emergency ContactEmergency Contact
Current MedicationsMedications
Known AllergiesAllergies
Diving History (if applicable)Long Text
8 min saved per patient98% patient satisfaction3x faster than paper

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