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Obispo Hyperbaric Oxygen Therapy

3196 S. Higuera Street, Suite C B1
San Luis Obispo, CA 93401
Tel. No.: (805) 440-9856
Email: obispohyperbaric@gmail.com
www.obispohyperbaric.com

PATIENT PROFILE

Full Name: Date: / /

Date of Birth: / / Age: □  Male □  Female
Address: City: State:

Zip Code: E-mail address:

Phone #: ( ) Alt. Phone #: ( )

Employer: Occupation:
Emergency Contact Name, Relation, & Phone Number:

How did you hear about us?

Known Allergies (Food, Drugs, Vaccines, or Environmental):

Current Health Concerns (Please list in order of priority):

1)

2)

3)

4)

5)

Current Medications (Prescription, Over the Counter Drugs, Vitamins, Herbs, Homeopathic Remedies, Etc.)

1) Dosage 4) Dosage

2) Dosage 5) Dosage

3) Dosage 6) Dosage

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Obispo Hyperbaric Oxygen Therapy
3196 S. Higuera Street, Suite C B1
San Luis Obispo, CA 93401
Tel. No.: (805) 440-9856
Email: obispohyperbaric@gmail.com
www.obispohyperbaric.com

PATIENT PROFILE
PLEASE ANSWER THE FOLLOWING QUESTIONS ON YOUR PAST OR PRESENT MEDICAL HISTORY
WITH YES OR NO. **If you are not sure, answer YES**

Could you be pregnant, or are you attempting to become pregnant? __________

Are you taking the following medications?

_______ Cisplatinum If yes, date last taken: _______________

_______ Disulphiram (Antabuse) If yes, date last taken: _______________

_______ Doxorubicin (Adriamycin) If yes, date last taken: _______________

Have you ever had or do you currently have…
Lung disease, any form
Emphysema
Pneumothorax/Collapsed Lung
Chest surgery
Heart Failure
Heart Disease
High Blood Pressure
Any diseases or conditions involving ears or sinus or surgical interventions
Difficulty in clearing ears during airplanes or pressurized environments like diving
Claustrophobia
Epilepsy/Seizures
Diabetes
Cataracts

Are you presently taking prescription medications for any of the above questions? If so, please specify:

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 a health care provider about this.

Signature: Date: / /

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