Are You a Candidate?

If you are looking for a non-conventional therapy that can give you the opportunity to restore your immune system and start living a healthy- free life style, then our treatment is suitable for your wellness and health expectations. We understand that the process of body detoxification and virus’s elimination is not an easy task when the immune system has been seriously compromised; however our goal is to heal and restore your immune system under our 95-day recovery treatment.

At Oxygen Clinic we know the value of privacy; therefore each recovery treatment has been designed to meet such expectations. During the whole recovery stay patients are monitored and checked in order to accomplish each step of their recovery treatment.

New Patient?

Print and complete the forms below and send them by fax or e-mail and/or bring them to your first appointment.

A) Financial Policy Information

B) Pre-Registration Form

C) Patient History Questionnaire

FINANCIAL POLICY

Thank you for choosing Oxygen Clinic as your specialty health care provider. Your understanding of our financial policy is an important part of your care and professional relationship. Please ask if you have any questions regarding our fees, Financial Policy, or your responsibility.

Full payment for office visit charges is due at the time of service. We accept cash, money order or electronic transfers. Should you need to make payment arrangements, please contact our Patient Accounts Specialist before your scheduled appointment. We will make every effort to reach mutually agreeable terms.

INSURANCE

Oxygen Clinic does not accept insurance for its treatments.

PAYMENT OPTIONS

Treatments for the 95 day immune system recovery should be paid prior arrival. Under certain circumstances, an instalment or financial arrangement can be negotiated. If payment cannot be made prior your treatment, you must contact our Patient Accounts Specialist to set up an extended payment arrangement.

I have read the Financial Policy of Oxygen Clinic. I understand that I am financially responsible for all charges. By my signature below I acknowledge that I have received a copy of the Oxygen Clinic Financial Policy.

 

ONLY FOR THE 95-DAY IMMUNE SYSTEM RECOVERY TREATMENT PLAN
PATIENT PRE-REGISTRATION FORM

Full Name

Mailing Address

City

State /Province

Postal / Zip Code

home phone

Cell phone

Sex  Male Female

Date of Birth

Email Address

REFERRING PHYSICIAN

Name

Address:

City

State /Province

Postal / Zip Code

MARITAL STATUS:

 Single Married Divorced Widowed

IF PATIENT IS A MINOR:

Father's Name

D.O.B.

Mother's Name

D.O.B.

Phone Number

Home Phone

Cell Phone

Email Address

EMERGENCY CONTACT (not living in same household):

Full Name

Phone

Date of Birth:

Relationship to patient:

RACE

 White/Caucassian Black/African American Hispanic

 American Indian or Alaska Native Asian or Other Pacific Islander

PATIENT QUESTIONNAIRE

Date

Patient Name

Were you referred by a physician?

If yes, by whom:

 Yes No

Were you referred by a friend or family member?

If yes, by whom:

 Yes No

Other physicians you have seen in the past year for this problem:

What is the MAJOR PROBLEM that prompted this visit?


I. SYMPTOMS:

(Please, explain all SYMPTOMS related with your medical indication).

How long have you been having these symptoms? How many years? months?

What are the TRIGGERS that make symptoms worse?

What is your diagnosis?

For how long you have been diagnosed? Years? Months?

Treatments in the past:


II. HAVE YOU BEEN DIAGNOSED WITH ANY HEART OR LUNG CONDITION?

(If you have a heart or lung medical condition, please fill out this section. If not, please go to the next section).


Heart Condition (please, explain)

Number of years:

Lung condition (please, explain)

Number of years:

TRIGGERS. Upper respiratory infections:


Frequency:

 Daily >2 times/week < 2 times/week # nights per month

Treatments tried for compromised immune system:

Emergency room visits

Total in last 12 months

Hospitalizations

Total in last 12 months


III. SKIN SYMPTOMS:

(If you are having SKIN SYMPTOMS, please fill out Section III. If not, please go to the next section).


What are your skin symptoms?

What are your skin symptoms?

 Hives Eczema Itching Swelling Rash

Swelling location:

How long have symptoms been present? No. of years/months/weeks:

TRIGGERS. Medications (name/date started taking):

Foods (name foods):

Frequency of reactions?

 All the time Daily Every few days Every few weeks

What symptoms occur with reactions?


IV. RECURRENT INFECTIONS:

(If you are having FREQUENT RESPIRATORY INFECTIONS, please fill out Section IV. If not, please go to the next section).

Number of bouts of otitis media (ear infections) - in life - in last 12 months PE tubes -Yes - No # of sets

Number of sinusitis in life and in last 12 months

Number of pneumonias in life and in last 12 months

Number of skin infections in life and in last 12 months> Body Location(s)

Number of recurrent croup episodes in life and in last 12 months

Number of hospitalizations for infections and Reason(s)

Number of antibiotics in last year and Name(s)

Have you had a previous immune workup?

 Yes No

Date

Have you had a sinus x-ray

 Yes No

Date

Have you had a sinus CT?

 Yes No

Date

V. FOOD REACTIONS:

(If you are having REACTIONS TO FOODS, please fill out Section VI. If not, please go to the next section).

Suspected food(s):

Age when reactions first started:

Frequency of reactions? daily / weekly / monthly Only with specific food ingestion:

Symptoms of the reactions?

Treatment

Visits


VI. OTHER MEDICAL INDICATIONS:

Is there a history of any of the following?

Asthma

 Yes No

Allergic rhinitis

 Yes No

Sinus Problems

 Yes No

Nasal

 Yes No

Atopic Dermatitis

 Yes No

Hives

 Yes No

Arthritis

 Yes No

Cancer

 Yes No

Heart Disease

 Yes No

Hypertension

 Yes No

Diabetes mellitus

 Yes No

Emphysema of the lung

 Yes No

Migraine

 Yes No

Rheumatoid arthritis

 Yes No

Lupus

 Yes No

Kidney disease

 Yes No

Seizure Disorder

 Yes No

Thyroid disease

 Yes No

Tuberculosis

 Yes No

Other diseases?


VII. SURGERIES:

Tonsillectomy

Date

 Yes No

Adenoidectomy

Date

 Yes No

PE tubes (ear tubes)

Date

 Yes No

Polypectomy (nasal polyp surgery)

Date

 Yes No

Septoplasty (nasal bone repair)

Date

 Yes No

Sinus Surgeries

Date

 Yes No

Other surgeries And Date

Other surgeries and Date


VIII. PAST MEDICAL HISTORY: (GENERAL PERSONAL HEALTH HISTORY):

Have you ever had any of the following? (Please, insert the year)

Anemia

Cancer

 Yes No

 Yes No

Cataracts

Chronic otitis media (ear infections)

 Yes No

 Yes No

Chronic sinusitis

Congestive heart disease (heart failure)

 Yes No

 Yes No

Coronary artery bypass graft

Coronary artery disease

 Yes No

 Yes No

Chemotherapy

Diabetes

 Yes No

 Yes No

Eczema/Dermatitis

Radiation

 Yes No

 Yes No

Gallstones

GERD (reflux)

 Yes No

 Yes No

Glaucoma (high eye pressure)

Headaches

 Yes No

 Yes No

Heart disease

Hepatitis

 Yes No

 Yes No

Hiatal Hernia

Hypertension (high blood pressure)

 Yes No

 Yes No

Hypercholesterolemia (high cholesterol)

Hypoglycemia

 Yes No

 Yes No

Irritable bowel disease (IRB)

Ulcerative colitis

 Yes No

 Yes No

Migraine headaches

Mitral valve prolapse

 Yes No

 Yes No

Pneumonia

Psoriasis

 Yes No

 Yes No

Rheumatic heart disease

Seizures

 Yes No

 Yes No

Stroke

Thyroid disease

 Yes No

 Yes No

Tuberculosis

Other illnesses/diagnoses not listed:

 Yes No


HOSPITALIZATIONS:

Reason

Date

Reason

Date

Reason

Date


IX. PRESENT MEDICATIONS: (List here or bring a list of current medications or bring all your medications with you):

A) List all MEDICATIONS taken PRESENTLY including over-the-counter preparations, prescription tablets, oral liquids, inhalers (MDI’s), nasal sprays, creams, or eye drops)

B) List all MEDICATIONS taken in the PAST, including over-the-counter preparations, prescription tablets, oral liquids, inhalers (MDI’s), nasal sprays, creams, or eye drops)

C) List OTHER MEDICATIONS taken routinely or intermittently for medical reasons (i.e., vitamins, aspirin, blood pressure medications, etc.)


X. SYSTEM REVIEW:

Please check those symptoms you may have experienced that have NOT been mentioned above.


GENERAL

Appetite loss

Fatigue

 Yes No

 Yes No

Night sweats

Weight change

 Yes No

 Yes No


SKIN

Dry skin

Change in Wart/Mole

 Yes No

 Yes No

Hives

Itching

 Yes No

 Yes No

Rash

Dry Eyes

 Yes No

 Yes No

Glaucoma

Glasses

 Yes No

 Yes No

Good Vision

 Yes No

Posterior nasal drainage

Clear runny nose

 Yes No

 Yes No

Itching of soft palate

Sneezing

 Yes No

 Yes No

Headache

Excessive tearing

 Yes No

 Yes No

Hearing loss

Ear infection

 Yes No

 Yes No

Earache

Ringing in ears

 Yes No

 Yes No

Vertigo

Nasal Congestion

 Yes No

 Yes No

Sinus pain

Hoarseness

 Yes No

 Yes No

Oral ulcers

Sore throat

 Yes No

 Yes No

Snoring

CPAP for Sleep Apnea

 Yes No

 Yes No


NECK

Neck mass

Neck pain

 Yes No

 Yes No

Neck stiffness

Swollen glands

 Yes No

 Yes No


RESPIRATORY

Shortness of breath

Chronic cough

 Yes No

 Yes No

Decreased Exercise

Tolerance

 Yes No

 Yes No

Difficulty breathing

Sputum production

 Yes No

 Yes No

Wheezing

 Yes No


CARDIOVASCULAR

Chest pain

Difficulty breathing

 Yes No

 Yes No

On exertion

Fainting/blacking out

 Yes No

 Yes No

Irregular heartbeat

Elevated blood pressure

 Yes No

 Yes No

Difficulty breathing

Lying down

 Yes No

 Yes No

Rapid heart rate

Swelling of extremities

 Yes No

 Yes No


GASTROINTESTINAL

Abdominal pain

Bloody stool

 Yes No

 Yes No

Constipation

Diarrhea

 Yes No

 Yes No

Difficulty swallowing

Heartburn

 Yes No

 Yes No

Indigestion

Nausea

 Yes No

 Yes No

Vomiting

 Yes No


MUSCULOSKELETAL

Back pain

Joint pain

 Yes No

 Yes No

Joint redness

Joint swelling

 Yes No

 Yes No

Muscle cramps

Muscle weakness

 Yes No

 Yes No


NEUROLOGICAL

Dizziness

Fainting

 Yes No

 Yes No

Headaches

Seizures

 Yes No

 Yes No

Stroke

Tremor

 Yes No

 Yes No


PSYCHIATRIC

Moodiness

Fussiness

 Yes No

 Yes No

Anxiety

Depression

 Yes No

 Yes No


ENDOCRINE

Appetite changes

Cold intolerance

 Yes No

 Yes No

Excessive thirst

Excessive urination

 Yes No

 Yes No

Hair changes

Heat intolerance

 Yes No

 Yes No

Heat intolerance

 Yes No


HEMATOLOGY

Anemia

Easy bruising

 Yes No

 Yes No

Enlarged lymph nodes

Nose bleeds

 Yes No

 Yes No

Patient Signature:

Date