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Name:
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Date of Birth
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Address
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Cellphone
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Email
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In case of emergency contact
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Have you ever had Ozone before?
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When?
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Where
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Did you have any reactions to ozone in the past?
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Do you have a history of thick blood:
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Do you take photo active medication
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Medications or supplements you are taking:
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Do you have drug or medication allergy?
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Are you allergic to heparin?
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Do you smoke tobacco or cannabis?
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What are your goals for today's procedure/treatment?
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Please answer yes or no to the following question:
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Are you currently pregnant
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Hypertension
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Congestive heart failure
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Severe Anemia
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Active Seizures
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Allergy to essential oils
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Cirrhosis
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Low Platelets
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Thyrotoxicosis
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Hyperthyroidism (Graves Ds)
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Constipation
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Heart condition
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Aneurysm
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Do you take IRON/Copper?
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Renal Insufficiency
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Parasitic infection
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RA/AS. Autoimmune Lyme or cancer
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Hemophilia or Blood disorder
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Do you have low G6PD
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Past Surgeries
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