SCREENING FORM

Name :

Sex :

Date of birth/ Age :

Nationality :

Address :

Vital signs

Blood pressure : / mmHg

Heart rate : beats per minute

Respiratory rate : times per minute

Temperature : °C

Oxygen saturation : % room air

Symptoms :

History Taking

Do you have previous allergic reaction to medicine, salt, infrared therapy, ozone therapy, cold?

History of past illness

 Autoimmune disease
 Cancer
 Hematologic and vascular disorders
 Skin disease/ open wound
 Eye problem
 Thyroid disorders
 Cardiac disorders
 Lung disorders
 Gastrointestinal disorders (anal fissure, bleeding, cirrhosis, hernia, crohn’s disease)
 Infection
 Trauma
 Surgery
 Claustrophobia

Are you currently receiving treatment right now?

If yes, please describe the treatment:
…………………………………………………………………………………………………………

Are you pregnant?

Have you ever been admitted to hospital?