Koh Phangan, Thailand info@holinaclinic.com +66 81 043 2380

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Start Here · Complete Before Your First Session

Treatment Intake Form

This is the first form every new patient completes — before any sessions begin. It covers HBOT, Stem Cell Therapy, and IV Infusions, and allows our clinical team to assess your suitability and design your personalised treatment plan.

Hyperbaric Oxygen Therapy · Stem Cell Therapy · IV Infusions & NAD+

HBOT, Stem Cells & Infusion Treatments Self Assessment Form

Personal Information

First name(Required)

Last name(Required)

Date of birth

DD slash MM slash YYYY

Age

Gender

ID / Passport Number

Phone Number

Email Address

Which treatment are you interested in?

Hyperbaric Oxygen Therapy (HBOT)

Stem Cells

Infusions

Physical Information

Current body weight (in KG)

Height (in CM)

Usual / Previous Weight (in KG)

Blood type

Rh Factor

Blood pressure (if known)

Do you have any blood born viruses?

Please specify

Reason for Treatment (HBOT)

What is the primary reason for your HBOT sessions?

Have you ever had a past pneumothorax (collapsed lung)?

Do you have difficulty equalizing ear pressure?

Do you have uncontrolled asthma or shortness of breath?

Do you have a history of seizures or epilepsy?

Are you currently pregnant or suspect you may be pregnant?

Do you have diabetes or issues with low blood sugar?

Do you currently have a cold, congestion, or ear pain?

Do you experience claustrophobia?

Regular medications and doses (please list all)

Important medical conditions (please specify)

I understand the possible side effects (ear pressure, headache, dizziness).

I understand the possible risks (barotrauma, rare oxygen-related seizures).*

I understand the possible risks (barotrauma, rare oxygen-related seizures).

I acknowledge the 5-minute late rule, 24-hour no-fly protocol, Membership and single session regulations, no-refund policy, and shared chamber.

I agree to HBOT Terms & Conditions

I agree to Terms & Conditions

https://holinarehab.com/hyperbaric-oxygen-therapy-terms-conditions/

Reason for Treatment (Stem Cells)

What is the main reason for your referral for stem cell treatment?

When did your symptoms first begin?

What treatments have you tried so far?

Please specify:

Previous Stem Cell Treatments

Have you had a stem cell transplant before?

Which year did you have a stem cell transplant before?

Reason for Treatment (NAD+ & Vitamin Infusions)

What is the main reason for your referral for NAD+ & Vitamin Infusions?

When did your symptoms first begin?

What treatments have you tried so far?

Please specify:

Have you been diagnosed with any of the following conditions?

Diabetes

High blood pressure

Heart disease

Kidney disease

Liver disease

Cancer

Autoimmune disease

Other

Please specify:

Have you had any surgeries in the past?

Please specify:

Have you received chemotherapy or radiation therapy?

When did you last receive chemotherapy or radiation therapy?

Medications

Are you currently taking regular medications?

Please list medication names and dosages:

Allergies

Do you have any allergies to medications or foods?

Please specify:

Lifestyle

Do you smoke?

Do you drink alcohol?

Do you use prescribed medication?

Please specify

Do you use non prescribed medications including illegal narcotics?

Additional Details

Any additional information the medical team should know:

Who referred you?

Please specify:

Patient Declaration

Full name(Required)

Information Declaration(Required)

I confirm that the information provided above is true and complete.

CAPTCHA

Δ

Why we ask

Your answers allow our clinical team to review your health background and recommend the most suitable treatment before your consultation.

What happens next

After submission, our team will review your form within one business day and contact you to confirm your consultation and treatment plan.

Confidential

All information is strictly confidential and reviewed only by the Holina medical team. We follow international clinical data standards.

Questions before completing?

info@holinaclinic.com +66 81 043 2380

Already in a treatment programme? Use the HBOT Outcome Assessment forms instead. · Need help? Contact the clinic

HOLINACLINIC

Back To Yourself

+66 81 043 2380

info@holinaclinic.com

14/1 Moo 8 Sri Thanu, Koh Phangan,
Surat Thani 84280, Thailand

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