Koh Phangan, Thailand info@holinaclinic.com +66 81 043 2380
HBOT · Step 1 of 4 · Required Before First Session

Pre-Treatment Assessment

Establishes your clinical baseline and informs your personalised treatment plan. All information is confidential and reviewed by the Holina medical team.

1
Pre-Treatment
2
Mid-Treatment
3
Post-Treatment
4
Extended
Approximately 25 minutes · 32 fields · Holina Clinic · Koh Phangan

Holina Clinic — HBOT Pre-Treatment Assessment

Baseline assessment — before your first 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 (Baseline)

This is the most important question. Be as specific as possible.
(minimum 10 characters)

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