Instructions: Below is a template for the pre-treatment patient history and consent for Hyperbaric Oxygen Therapy treatment, which can be adapted to fit your needs. A fillable PDF is attached for your convenience. Prior to use, ensure the adapted version is reviewed and approved by responsible parties within the HBO clinic/hospital.

IDENTIFICATION

Patient Name: __________________________________________ Date_____________________

Referring MD:____________________________________________________________________________

RISK FACTORS 

 Seizures/Epilepsy                                                            COPD Emphysema

 Previous Pneumothorax                                                  Asthma

 Recent URI                                                                      Thoracic Surgery

 Ear Problems                                                                   Sinus Problems

 Heart Disease                                                                  Bleomycin exposure

 Adriamycin (Doxorubicin) exposure                                 Pregnancy

 Untreated Cancer                                                            Smoker (Past or present)

 Recent Virus                                                                    Claustrophobia

 Uncontrolled Fever                                                          History of Optic Neuritis

 Hereditary Spherocytosis                                                Cataracts

 Implanted Device                                                            History of ear bone surgery

Comments:______________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

Recent EKG Date:______________________________________ Recent CXR Date: __________________________

RN/Tech Signature:______________________________________________ Date:_________________________

INFORMED CONSENT FOR TREATMENT

I, _________________________________________, hereby grant consent to and authorize Hyperbaric Medicine Service, 

its physicians, employees, and agents to treat me with HYPERBARIC OXYGEN THERAPY for the condition of: 

___________________________________________________________________________________________________________________________

Further, I understand that hyperbaric oxygen therapy might call for more than one treatment and I hereby authorize the hyperbaric physicians to determine the number of treatments necessary to treat my condition.

Benefits Associated with Hyperbaric Oxygen Therapy

1. Raising the tissue oxygen levels in order to enhance healing of difficult wounds
2. Reverse toxic effects of chemicals or inhaled gases
3. Decreasing/abolishing bubbles in vessels or body tissues
4. Enhancing antibiotic penetration to infected tissues, and/or stopping bacterial toxin production
5. Growing healing tissue in areas that have been radiated

Risks Associated with Hyperbaric Oxygen Therapy

1. Oxygen toxicity-central nervous system (seizure/fits)/lung (difficulty or painful breathing)
2. Eardrum pain, bleeding, and/or rupture; sinus pain; dental pain
3. Myopia, vision change (Usually reversible after HBOT stops)
4. Increased cataracts growth rate (thickening of lens/change in vision)
5. Increased risk of fire
6. Over-pressurized lung; gas or air embolism; pneumothorax; air trapping diseases (collapsed lung/bubbles in bloodstream)
7. If you have diabetes, your blood glucose may drop while in the chamber
8. Pulmonary edema (lung fluid accumulation)

The nature and purpose of hyperbaric oxygen therapy has been explained to me by Dr. _______________________________ 

and I hereby acknowledge that I know and understand the nature and the purpose of the treatments. Additionally, the physician has explained to me the consequences, benefits, risks, and alternatives to receiving hyperbaric oxygen treatment. 

I have been given the opportunity to ask questions and have them answered so that I can form my own decision.

Patient Signature:_____________________________________________________________________

Date/Time_______________________

Relationship, if not Patient:________________________ Witness: ___________________________DO / MD / RN

___________________________________________________________________________________________________________

I have explained the nature, purpose, prognosis and possible consequences of diagnostic and/or treatment procedures, and the risks involved, possible associated complications and alternative treatments of diagnostic and/or treatment procedures.

Physician Signature:______________________________________________

Date/Time_______________________

Informed Consent for Needle Myringotomy, as required

I hereby grant consent to the consulting hyperbaric physician to perform a needle myringotomy. This involves making a hole in my eardrum to relieve pressure, pain, and bleeding. The risks and benefits have been explained and questions have been answered. 

Patient is presently:   Unconscious   Conscious Treatment is:   Emergent   Non-emergent

Risks of Myringotomy: 1. Infection 2. Persistent perforation (hole) 3. Hearing loss or muffled hearing

Patient Signature:______________________________________________________

Date/Time_________________________________

Relationship, if not Patient:___________________    Witness: ______________________________ DO / MD / RN