Colon Hydrotherapy Health Questionnaire

CLIENT INFORMATION:

Today's Date:

Name:

First

Last

Referred by:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number:

Cell Phone Number:

Email:

Occupation:

Height:

Weight:

Birthdate:

Name of Primary Care Physician:

Physician Phone:

Physician Address:

Address Line 1

Address Line 2

City

State

Zip Code

Do you see an Alternative or Holistic Doctor?

Yes
No

Do you see a Chiropractor?

Yes
No

Are you currently under a Doctor's care?

Yes
No

If yes, please explain:

Have you ever had a colonoscopy?

Yes
No

If yes, when and what were the results?

Have you had surgery of any kind in the past 1 year?

Yes
No

If yes, please explain:

List any medications you are taking, including hormones, vitamins, herbs, and nonprescription, and over the counter medications:

List all supplements:

Please mark all CURRENT health challenges:

Please mark all PAST health challenges:

Are you pregnant at this time?

Yes
No

Number of previous pregnancies:

Mark each that applies to you:

Water:

Yes
No

Amount per day/week:

Dairy:

Yes
No

Coffee:

Yes
No

Amount per day/week:

Tea:

Yes
No

Amount per day/week:

Soda:

Yes
No

Amount per day/week:

Tobacco:

Yes
No

Amount per day/week:

Alcohol:

Yes
No

Amount per day/week:

Salt Cravings:

Yes
No

Vegetarian/Vegan:

Yes
No

Sugar Cravings:

Yes
No

Diet Programs:

Yes
No

Exercise:

Yes
No

Restful Sleeper?

Yes
No

Average hours per night:

Bowel Habits

Last Bowel Movement:

How often do you have a bowel movement per day?

How often do you have a bowel movement per week?

Which applies to your bowel movements:

Effortless?
Straining?
Mix of both?

Do you have hemorrhoids?

Yes
No

If yes are they currently (choose all that apply):

Inflamed?
Bleeding?

Have you ever had rectal or colon surgery?

Yes
No

If yes, please explain:

Do you use (check all that apply):

Laxatives?
Stool softeners?
Suppositories?
Enemas?

Have you ever had colon hydrotherapy done before?

Yes
No

If yes, when and where?

CLIENT CONSENT

SIGN BY TYPING YOUR NAME BELOW TO ATTEST TO THE FOLLOWING: I have answered these questions to the best of my knowledge, and I attest that my answers are true. I will notify my colon hydrotherapy technician immediately should any of the above information or conditions change.

SIGN BY TYPING YOUR NAME BELOW TO ATTEST TO THE FOLLOWING: I have read, acknowledged, and agree to the Colon Hydrotherapy Informed Consent and Liability Release Form and Agreement and Release of Liability:

Please click HERE to read our Colon Hydrotherapy Informed Consent and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Colon Hydrotherapy Informed Consent and Liability Release Form and Agreement and Release of Liability.

Wellness Services

Please note…

CLIENT INFORMATION:

Mark each that applies to you:

Bowel Habits

CLIENT CONSENT

Contact Us

Hours

Well of Life Center for Holistic Healthcare

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