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New HBOT Candidate?
Initial Questionnaire
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Letter Drive
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Giddy Up & Go: 2015
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4th of July Sandcastle Competition
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Best Bite on the Ave – 2014
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South Florida Health & Wellness: December 2014
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Third Thursday Fun-raiser
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Home
How HBOT Works
About
Programs
Community Partners
Meet the Team
New HBOT Candidate?
Initial Questionnaire
Grant Application
Contact
Donate Now
Home
How HBOT Works
About
Programs
Community Partners
Meet the Team
New HBOT Candidate?
Initial Questionnaire
Grant Application
Contact
Donate Now
Initial Questionnaire
Please complete the form below. An asterisk indicates a required entry.
Today's Date
*
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
1. Have you received HBOT before?
*
Yes
No
2. If you have had HBOT before, please list the number of sessions, the date of your last treatment, and where you were treated.
3. I can speak.
*
Yes
No
4. I can walk.
*
Yes
No
5. I have cognitive issues.
*
Yes
No
6. If you have cognitive issues, please describe them:
7. I am receiving chemotherapy.
*
Yes
No
8. I have lung issues.
*
Yes
No
9. I have ear issues.
*
Yes
No
10. I experience headaches.
*
Yes
No
11. I have a pacemaker and/or defibrillator.
*
Yes
No
12. I experience seizures.
*
Yes
No
13. If you have seizures, are they under control?
Yes
No
14. If you have seizures, are you taking medication?
Yes
No
15. Enter the date of your last known seizure.
16. Describe the type of your last known seizure.
17. Are you currently involved in any open or pending litigation?
*
Yes
No
18. Do you require financial assistance to proceed with hyperbaric oxygen therapy treatment?
*
Yes
No
19. What condition are you seeking treatment for?
*
Brain Injury (or concussion)
Post-Traumatic Stress
Other
20. Are/Were you a member of the US Military?
*
Yes
No
21. Are you currently employed?
*
Yes
No
22. If you are employed, please list the company and your job title.
Phone
This field is for validation purposes and should be left unchanged.
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