Koh Phangan, Thailand info@holinaclinic.com +66 81 043 2380
HBOT · Step 3 of 4 · Completed at Programme Conclusion

Post-Treatment Assessment

Measures your outcomes against the pre-treatment baseline and informs any follow-up recommendations from the clinical team.

✓
Pre-Treatment
✓
Mid-Treatment
3
Post-Treatment
4
Extended
Approximately 20 minutes · 37 fields · Holina Clinic · Koh Phangan

Holina Clinic — HBOT Post-Treatment Assessment

Full outcome assessment after your final HBOT session. ~5-7 minutes.

Client Information

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DD slash MM slash YYYY
Please enter a number from 0 to 999.

WHO-5 Wellbeing Index

Over the last 2 weeks, how often have you felt this way?
I have felt cheerful and in good spirits(Required)
I have felt calm and relaxed(Required)
I have felt active and vigorous(Required)
I woke up feeling fresh and rested(Required)
My daily life has been filled with things that interest me(Required)

ISI — Insomnia Severity Index

Please rate the current (last 2 weeks) severity of your sleep problem(s).
Difficulty falling asleep(Required)
Difficulty staying asleep(Required)
Problems waking up too early(Required)
How satisfied/dissatisfied are you with your current sleep pattern?(Required)
How noticeable to others do you think your sleep problem is in terms of impairing your quality of life?(Required)
How worried/distressed are you about your current sleep problem?(Required)
To what extent do you consider your sleep problem to interfere with your daily functioning?(Required)

VAS Sliders — Energy, Pain, Clarity

On a scale of 0-10, please rate each of the following right now. (Implement as a horizontal slider via Gravity Perks Range Slider or CSS; default field type is numeric input.)
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.

Client Goal (Final)

Your original goal:
Pulled from Airtable client_goal via dynamic population.

Outcome Narrative

(minimum 20 characters)
Do you consent to us using your anonymised responses for clinical research or case studies?(Required)

Consent

PDPA Consent(Required)
I consent to my responses being used for clinical monitoring and treatment planning purposes in accordance with Thailand's Personal Data Protection Act (PDPA). All data is held confidentially and used solely to guide my treatment at Holina Clinic.

Having trouble? Contact the clinic at info@holinaclinic.com or +66 81 043 2380.  ·  ← Back to form selection