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HYPERBARIC OXYGEN THERAPY FORM

If you have any medical conditions or are on certain medication.You should check with your doctor before having HBOT.We will need to ask you some health questions ensure a safe service and to provide industry specific advice.HBOT may not be suitable for you if you suffer from the below conditions or are on certain medications.

 

Should you fail to provide the necessary information for safe and proper treatment YHB LTD will not be held liable for any illness or injury caused.Necessary information includes, but is not limited to -any medical diagnosis, medical concerns, prescription medications, controlled substances, alcohol, vitamins and homeopathic remedies.

 

Where we collect information about your health or medical circumstances we have a legal obligation to collect this information for health and safety and insurance purposes and only do so with your explicit consent. The privacy and security of your data is very important to us and we will only use health related information for the purposes described on this form and in our privacy notice.

CLIENT PROFILE

Please answer the following YES or NO if you are unsure answer YES

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

Have you ever had or do you currently have any of the following (Please choose)

Please tick where applicabe.

I hereby consent and authorise the HBOT staff at Your Health Bank to administer HBOT to me.I hereby acknowledge the following-

 

CONTRAINDICATIONS/AREAS OF CONCERN

 

ABSOLUTE CONTRAINDICATION

 

The only absolute contraindication to receiving HBOT is an untreated pneumothorax (collapsed lung) due to the possibility of converting it to a tension pneumothorax as the intra-pleural air expands on decompressing.All other contraindications are, to a more or lesser degree, relative

 

RELATIVE CONTRAINDICATIONS

 

BLEOMYCIN

Cases of fatal interstitial pneumonitis have been reported in clients who were administered elevated oxygen concentrations months to years after receiving bleomycin therapy.Elective therapy with HBOT is contraindicated in clients with even a remote history of bleomycin administration.

However, in emergency, life threatening situations the benefits of HBOT might outweigh the possibility of bleomycin toxicity 

 

DOXORUBICIN

Administering HBOT concurrently with doxorubicin was associated with cardiac toxicity.It is advisable to wait until the drug has been cleared from the body before initiating HBOT

CIS-Platinum

In animals concurrent administration of HBOT and cis-platinum was associated with an increase in wound breakdown.HBOT should be held off until cis-platinum therapy is finished if possible.

 

DISULFIRAM

Disulfiram blocks the production of superoxide dismutase, which could lead to decreased free radical scavenging in hyperbaric environments.

 

MAFENIDE ACETATE (SULFAMYLON)

Increases the possibility of oxygen toxicity seizures

 

UPPER RESPIRATORY TRACT INFECTIONS OR CHRONIC SINUSITIS

These conditions can make it hard to clear the ears and/or can lead to significant sinus squeeze

 

SEIZURE DISORDERS

Increased risk of oxygen-induced seizures.

 

EMPHYSEMA WITH C02 RETENTION

 

Small risk of blunting hypoxic respiratory drive and/or rupturing of a pleb during accent leading to pneumothorax.This is contested by some physicians, so while it is scientifically possible it is not observed that often

 

PREGNANCY

 

There are at least theoretical concerns with the administration of hyperbaric oxygen therapy during pregnancy.These primarily centre around the possible deleterious effects of hyperopia on the foetus.Clinical experience has failed to support these concerns and there is no evidence that hyperbaric sessions cause harm to the mother or child.The use of HBOT to treat emergency ,life threatening conditions is deemed safe, but elective therapy should probably be held off until after delivery if possible.

 

KNOWN MALIGNANCIES

There is some theoretical concern that HBOT might enhance the growth of some tutors, especially those that have outgrown their blood supply. However there is no clinical or experimental evidence that this occurs.Currently, known or active malignancies are not considered a contraindication to HBOT, but close monitoring of the lesion is probably indicated.

 

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IMPLANTED DEVICES SUCH AS PACEMAKERS

Early pacemakers, such as those made in the 1960’s contained air-filled voids that did not tolerate pressurisation well and led to damage or malfunction of the devices.Most currently produced pacemakers do not suffer from these problems and their manufacturers have certified them as safe in hyperbaric environments. Other implemented devices such as medicine pumps and nerve simulators are often not certified for greater pressure than one atmosphere of pressure.If there is any question about a device’s suitability, the manufacturer should be contacted before HBOT treatments are initiated.

 

FEVERS

This is discouraged as HBOT may exacerbate a high fever to a degree.

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FLIGHTS

No flights until 24 hours after treatment 

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