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C
Clients
"
*
" indicates required fields
Name
*
Phone
*
Email
*
Date of Birth
*
Height
*
Weight
*
Occupation
How did you find our clinic? - Internet, Friend, Sign, Health professional, Other
Do you have any of the following?
Acid reflux
Allergies
Anxiety
Arthritis
Asthma
Bad breath
Bloating
Cancer
Constipation
Depression
Diabetes
Diarrhea
Endometriosis
Gas
Headaches
High/low blood pressure
Hernia
Heart condition
IBS
Kidney disease
Liver disease
PCOS
Pregnant
SIBO
Skin disorder
Thyroid condition
Have you had in the past or presently have any of the following?
Colon cancer
Chroh's disease
Diverticulitis
Inflammatory bowel disease
Ulcerative colitis
How much water do you drink each day?
*
Do you sleep well?
Are you tired in the morning?
Are you tired in the afternoon?
Do you smoke?
Amount per week
Do you drink alcohol?
Amount per week
How often do you exercise?
How often do you have bowel movements?
1 per day
2 per day
Less than 1 per day (please specify)
Do you presently have?
Hemorrhoids
Rectal bleeding
Bowel strain
Blood in stools
Do you have any other health issues? Please describe
Are you taking any medication or supplements? Please list
Have you had colon/bowel surgery or investigatons(colonoscopy etc) in the last 5 years?
Yes
If yes, please describe
Treatment consent
Consent
*
The information provided is accurate to the best of my knowledge and belief. I consent to the treatment of colon hydrotherapy/ irrigation. I am aware that in some instances, depending on my present state of health, that some mild discomfort/cramping may occur. Perforation of the bowel is extremely rare and may occur in less than 1 in 20,000.
Print name
Date
Notes
"
*
" indicates required fields
Name
*
Phone
*
Email
*
Date of Birth
*
Height
*
Weight
*
Occupation
How did you find our clinic? - Internet, Friend, Sign, Health professional, Other
Do you have any of the following?
Acid reflux
Allergies
Anxiety
Arthritis
Asthma
Bad breath
Bloating
Cancer
Constipation
Depression
Diabetes
Diarrhea
Endometriosis
Gas
Headaches
High/low blood pressure
Hernia
Heart condition
IBS
Kidney disease
Liver disease
PCOS
Pregnant
SIBO
Skin disorder
Thyroid condition
Have you had in the past or presently have any of the following?
Colon cancer
Chroh's disease
Diverticulitis
Inflammatory bowel disease
Ulcerative colitis
How much water do you drink each day?
*
Do you sleep well?
Are you tired in the morning?
Are you tired in the afternoon?
Do you smoke?
Amount per week
Do you drink alcohol?
Amount per week
How often do you exercise?
How often do you have bowel movements?
1 per day
2 per day
Less than 1 per day (please specify)
Do you presently have?
Hemorrhoids
Rectal bleeding
Bowel strain
Blood in stools
Do you have any other health issues? Please describe
Are you taking any medication or supplements? Please list
Have you had colon/bowel surgery or investigatons(colonoscopy etc) in the last 5 years?
Yes
If yes, please describe
Treatment consent
Consent
*
The information provided is accurate to the best of my knowledge and belief. I consent to the treatment of colon hydrotherapy/ irrigation. I am aware that in some instances, depending on my present state of health, that some mild discomfort/cramping may occur. Perforation of the bowel is extremely rare and may occur in less than 1 in 20,000.
Print name
Date
Notes
