Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 1

** THIS FORM MUST BE RECEIVED BY OUR OFFICE BEFORE YOU CAN MAKE AN APPOINTMENT**

For Office Use Only: Date Received: __________ Date of Initial Evaluation: ______________

HBOT QUESTIONNAIRE:

PERSONAL INFORMATION:

Patient Name: _______________________

Home Address: ___________________________________Phones: (Home) _______________________

______________________________________ (Cell) _______________________

Email: ________________________________ (Work) _______________________

Date of Birth: ____/____/____ ____ Female ____ Male

Parent Name (if patient is a child): ____________________________

PRIMARY PRACTITIONERS

NAME PHONE NUMBERS CITY, STATE LAST VISIT

SPECIALISTS

NAME SPECIALTY PHONE NUMBERS CITY, STATE LAST VISIT

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 2

CHIEF COMPLAINT OR CURRENT ILLNESS

What are your major CURRENT health problems/concerns?

PROBLEM and BRIEF DESCRIPTION DATE OF ONSET FREQUENCY

(daily, weekly…)

SEVERITY

(mild, moderate

or severe)

Is this problem a result of an injury? YES or NO (circle one)

If yes, please describe the injury in detail:

_________________________________________________________________________________

_________________________________________________________________________________

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 3

When did the injury occur?

_________________________________________________________________________________

What therapies, medication or other interventions have you tried (not if positive, negative or no response to

each)?

_________________________________________________________________________________

_________________________________________________________________________________

Reason for HBOT Evaluation:

_________________________________________________________________________________

_________________________________________________________________________________

Please describe HBOT history if you have done any session in the past (specify hard or soft chamber, where it

was done, number of sessions completed, response, etc.):

_________________________________________________________________________________

_________________________________________________________________________________

PAST MEDICAL HISTORY:

* Include any chronic/recurring disorder or previously treated problems/diseases which no longer affect you *

CONDITION PAST TREATMENTS

CURRENT TREATMENTS APPROXIMATE

DATE (S) of TREATMENT

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 4

PAST MEDICAL HISTORY continued:

* Include any chronic/recurring disorder or previously treated problems/diseases which no longer affect you *

CONDITION PAST TREATMENTS

CURRENT TREATMENTS APPROXIMATE

DATE (S) of TREATMENT

Do you have a history of any of the following medical problems?

CONDITION YES NO If YES, please explain

Epilepsy or seizure disorder

Pneumothorax/ Collapsed Lung

Asthma or emphysema

Cataracts

Optic neuritis

Heart Failure

Heart Problems

Retinopathy of prematurity

Dental Disease

Have you ever had a concussion? YES or NO (circle one)

If yes, please describe the trigger (sports injury, accident, etc.) and recovery (length of time, interventions,

etc.): _________________________________________________________________________________

_________________________________________________________________________________

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 5

How many concussions have you had? ________

What was the date of your last concussion?_________________

SURGICAL or HOSPITALIZATION HISTORY:

Chronologically list major/minor surgeries and hospitalizations you have had or are planning – include dates

and complications

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

ALLERGIES

Do you have any known Allergies to medications? If yes, please list names and describe reactions to

medication:

________________________________________________________________________________________

________________________________________________________________________________________

Please note any other Allergies (such as latex, neoprene) If yes, please list names and describe reactions:

________________________________________________________________________________________

________________________________________________________________________________________

MEDICATIONS AND SUPPLEMENTS

Please list any medications, supplements, therapies or other interventions that you currently use:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 6

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please list any devices or hardware in your body:

________________________________________________________________________________________

________________________________________________________________________________________

Smoker: YES or NO (circle one)

Are you pregnant: YES or NO (circle one)

If no, do you plan to try to get pregnant within the next 6 months? YES or NO

FAMILY HISTORY:

List any allergies, major illnesses, genetic diseases or problems for each family member. ** If any family

members are deceased, please also list their age at death and cause.

Mother

Father

Siblings

Other pertinent family

history

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 7

List any related labs, imaging studies or evaluations (please send copies)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

REVIEW OF SYSTEMS AND OTHER HISTORY:

CURRENT PROBLEM PAST PROBLEM NEVER A PROBLEM

Chills or Fever

Fatigue

Rashes

Wounds that will not heal

Headaches

Ear infections

Sinus infections

Congestion

Frequent colds

Nosebleeds

Eye problems

Cough

Shortness of breath

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 8

Continued…

CURRENT PROBLEM PAST PROBLEM NEVER A PROBLEM

Abdominal pain

Diarrhea

Constipation

Hypertension

Chest pain

Irregular heart beat

Leg pain after short walk

Difficulty breathing

Painful urination

Frequent urination

Kidney stones

Seizures

Poor memory

Anxiety

Numbness in any body

part

Depression

Mood swings

Irritability

Insomnia

Muscle pain

Fractures

Center for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLCCenter for Integrative Health, LLC

Nancy H. O'Hara, MD & Gail M. Szakacs, MD

3 Hollyhock Lane Wilton, CT 06897

Tel: 203-834-2813 Fax: 203-834-2831

PATIENT NAME: ____________

HBOT Questionnaire, March 2016 9

Continued…

CURRENT PROBLEM PAST PROBLEM NEVER A PROBLEM

Joint pain or stiffness

Claustrophobia

Panic attacks

Other (please describe any other problem you have in any organ system not mentioned above):

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________