lang="en-US"> Extended Pre-Treatment Assessment – Holina Clinic
Koh Phangan, Thailand info@holinaclinic.com +66 81 043 2380
HBOT · Step 4 of 4 · For Extended Treatment Protocols Only

Extended Programme Assessment

For patients on extended HBOT protocols of 20 or more sessions. Includes additional neurological and physiological tracking metrics for long-term programme management.

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Pre-Treatment
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Mid-Treatment
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Post-Treatment
4
Extended
Approximately 35 minutes · 52 fields · Holina Clinic · Koh Phangan

Extended programme patients only. This form is for patients completing 20 or more HBOT sessions. If you were directed here in error, please return to form selection.

Holina Clinic — HBOT Extended Pre-Treatment Assessment

Extended baseline (Dr. Lilach discretion — complex cases). ~10-12 minutes.

Client Information

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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)

PHQ-9 Depression Screener

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things(Required)
Feeling down, depressed, or hopeless(Required)
Trouble falling or staying asleep, or sleeping too much(Required)
Feeling tired or having little energy(Required)
Poor appetite or overeating(Required)
Feeling bad about yourself — or that you are a failure or have let yourself or your family down(Required)
Trouble concentrating on things, such as reading the newspaper or watching television(Required)
Moving or speaking so slowly that other people could have noticed — or so fidgety or restless that you have been moving around a lot more than usual(Required)
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way(Required)

GAD-7 Anxiety Screener

Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge(Required)
Not being able to stop or control worrying(Required)
Worrying too much about different things(Required)
Trouble relaxing(Required)
Being so restless that it's hard to sit still(Required)
Becoming easily annoyed or irritable(Required)
Feeling afraid as if something awful might happen(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

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