(Confidential Information)

This is a statement in which you are informed of potential risks involved in receiving elective wellness pressurization experiences and of the conduct required of you during the Dive(s).

Your signature on this statement is required for you to participate in any experience offered by this hyperbaric facility and their designated chamber operators. Read and discuss this statement prior to signing it.

You must complete this Medical Statement, which includes the medical history section, to “dive.” If you are a minor, you must have this statement signed by a parent or legal guardian.

Hyperbaric dives are benign and generally safe with relatively few negative side effects and contraindications. When established safety procedures are not followed, there is increased risk. Your respiratory system must be in good health.

All body air spaces must be normal and healthy. A person with a current cold or chest or sinus congestion should not dive. If taking any medication, list it in the space provided. Include dietary supplements and IV therapies.

You will need to learn the rules regarding sinus and ear equalization during pressurization. For questions regarding this Medical Statement or the Medical History section, review them with your chamber operator before signing.

MEDICAL HISTORY

To the Participant: The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in any elective wellness pressurization experience.

A positive response does not necessarily disqualify you from “diving.” It means that there is a preexisting condition that may affect your safety while experiencing pressurization and therefore you must seek the advice of your physician.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we may request that you consult with a physician prior to participation.

Date of Birth

Do you regularly take prescription or nonprescription medications? If so, please list here:

Have you ever had or do you currently have:

Asthma, or wheezing with breathing, or wheezing with exercise?

Any form of lung disease?

History of diving accidents or decompression sickness?

Frequent colds, sinusitis, or bronchitis?

Frequent or severe attacks of hay fever or allergy?

History of chest surgery?

Pneumothorax (collapsed lung)?

History of recurrent back problems?

History of bleeding or other bleeding disorders?

History of back surgery?

Recurring migraine headaches or take medications to prevent them?

History of diabetes?

History of back, arm, or leg problems following surgery, injury, or fracture?

History of HIV/AIDS?

Epilepsy, seizures, convulsions, or take medications to prevent them?

History of drug or alcohol abuse?

History of blackouts or fainting (full/partial loss of consciousness)?

History of colostomy?

History of ear disease, hearing loss, or problems with balance?

History of heart attacks?

History of problems equalizing (popping) ears with airplane or mountain travel?

History of cancer therapy or treatment?

Behavioral health problems?

History of ear or sinus surgery?

Claustrophobia (fear of closed or confined spaces)?

Any medical problem not listed?

If yes, please specify:

The information I have provided about my medical history is accurate to the best of my knowledge.

Signature

Date

Signature of Parent or Guardian (where applicable)

Print Name

Date

State your Name if you consent to participate in this elective wellness pressurization experience, which is not intended to treat, diagnose, cure, or prevent any disease.

Address

Phone

Email