INTAKE FORM

Intake Form

IMPORTANT: COMPLETE 24 HOURS PRIOR TO YOUR APPOINTMENT
Clinic: REDCON1 MEDICAL SPA

Date Of Birth:*
Address*

HYPERBARIC TREATMENTS AND CURENT MEDICATIONS

Intake Form

History and Current Medications

Are you taking any medication?*

Current Medication:

Are You Taking Any Other Medication?*

Second Current Medication:

Are You Taking Any Other Medication?*

Third Current Medication

Are You Taking Any Other Medication?*

Fourth Current Medication

Are You Taking Any Other Medication?*

Fifth Current Medication

Are You Taking Any Other Medication?*

MEDICAL CONCERNS CHECKLIST

To Best Qualify Your Medical Treatment Please Answer The 17 Checklist Concern Questions

High Blood Pressure Or Taking Blood Pressure Medication History*
Ear Or Sinus Disease History*
Lung Disease, Heart Disease, Older, Sicker History*
Do You Have Asthma*
Do You Experience Claustrophobia*
Do You Have Poor Blood Sugar Control And/Or Insulin-Dependent Diabetic*
Do You Have Cataracts*
Have You Ever Had Seizure Disorders/Epilepsy, Or Taking Anti-Seizure Medication(s)*
Have You Ever Had An Uncontrolled High Fever*
Do You Have Diabetes*
Have You Ever Had Congenital Spherocytosis Or Sickle Cell Anemia*
Have You Ever Been Diagnosed With Lung Disease, COPD, Emphysema, Collapsed Lung, Or Fluid In The Lungs*
Do You Have Any History Of Chest Surgery*
Are You Pregnant?*
Have You Ever Been Diagnosed With Cancer*
Have You Ever Had Any Any Cardiac Events Or Heart Failures*
Do You Have Any Implanted Medical Devices? This Includes Pacemakers, Deep Brain Stimulation, And All Other Electronic Medical Device Implants)*

CONSENT FORM

REDCON1 RECOVERY, a Florida-based company. Dr. Robert W. Schneider, DO serves as the hyperbaric advisor.

Safety Screening Report
By choosing the safety screening report then:

  • I understand that this report is a “general risk assessment report” for hyperbaric oxygen therapy and the results of this report are solely based on my answers to the hyperbaric screening questionnaire on the online intake form.
  •  I have accurately and to the best of my knowledge filled out the Intake Form for the hyperbaric screening online application.
  • I understand that this report is not a prescription and will not be signed by a REDCON1 RECOVERY. If I wish to proceed with hyperbaric therapy, then I will take this report to my doctor and get him/her to sign the physician statement before I begin hyperbaric therapy.

Professional Assessment — From REDCON1 RECOVERY

REDCON1 RECOVERY is an independent licensed healthcare practitioner trained in hyperbaric therapy and REDCON1 RECOVERY may or may not call you if they have questions based on these answers. If I choose to have a REDCON1 RECOVERY review my screening report and give their professional assessment of my fitness for undergoing hyperbaric therapy then:

  • I understand that this is an “assessment for hyperbaric fitness” and the results of this assessment are solely based on my answers to the hyperbaric screening questionnaire on the online intake form.
  • I have been recently been evaluated within the past 6 months by a licensed medical doctor for my health (and have not had any changes in my health status since this evaluation) and have accurately filled out any diagnosis of any medical condition or any medication that I have been prescribed and made this aware and in detail during this screening process. This includes any changes in health or medication status since my last doctors visit.
  • Since both past and current medical history are pertinent and of primary importance to proper safety screening, I hereby agree that I will accurately disclose all truthful information to REDCON1 RECOVERY and hold harmless REDCON1 RECOVERY LLC, Dr. Robert W. Schneider, DO and all REDCON1 RECOVERYs should I fail to provide necessary information for safe and proper administration. “Necessary information” includes, but is not limited to, any safety screening medications, controlled substances, alcohol, homeopathic remedies, vitamins, and any other over-the-counter items that I am currently taking that could affect my sessions inside the chamber.
  • If I am assessed for being “fit” to be inside a hyperbaric chamber by REDCON1 RECOVERY, then I agree to immediately let my current physician know and get their recommendation before proceeding.
  • If I am using this assessment for:
    • General Health and Wellness, then I understand that it is only to try to help me to improve my physiologically available levels of oxygen, with the primary goal to help support my body for optimal cellular functioning.
    •  A Medical condition, then I will first take this assessment, along with the full safety screening report, to my doctor so that he/she can sign the physician statement on the last page of the safety screening report.

Physician Statement — From REDCON1 RECOVERY

At this time, Dr. Robert W. Schneider, DO will be providing consultations for signed Physician Statements (for hyperbaric approvals). If I choose to have a hyperbaric consultation with Dr. Robert W. Schneider, DO to sign my paperwork then:

  • I understand that this will be a Telehealth consultation and will not be seeing Dr. Robert W. Schneider, DO in person and the paperwork will be from Dr. Robert W. Schneider, DO’s License in the state of Florida.
  •  I have been recently been evaluated within the past 6 months by a licensed medical doctor for my health (and have not had any changes in my health status since this evaluation) and have accurately filled out any diagnosis of any medical condition or any medication that I have been prescribed and made this aware and in detail during this screening process. This includes any changes in health or medication status since my last doctors visit.
  •  Since both past and current medical history are pertinent and of primary importance to proper safety screening, I hereby agree that I will accurately disclose all truthful information to REDCON1 RECOVERY and hold harmless REDCON1 RECOVERY LLC, Dr. Robert W. Schneider, DO and all REDCON1 RECOVERY should I fail to provide necessary information for safe and proper administration. “Necessary information” includes, but is not limited to, any safety screening medications, controlled substances, alcohol, homeopathic remedies, vitamins, and any other over-the-counter items that I am currently taking that could affect my sessions inside the chamber.
  •  If I am using this physician statement for:
    • General Health and Wellness, then I understand that it is only to try to help me to improve my physiologically available levels of oxygen, with the primary goal to help support my body for optimal cellular functioning.
    •  A Medical condition, then I will first take this signed document, along with the full safety screening report, to my doctor so that he/she can make a final approval.

Consent Affirmation*
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