COLON HYDROTHERAPY

Name...... Marital status......

Address...... Post code......

Mobile Number...... Email address......

Date of Birth...... Age ...... Height...... Weight......

Children...... Occupation......

How did you find / hear about the clinic? Please circle Internet / Local Advertisement / Friend /Other

Main complaint / reason for colonic......

Present medical history......

Previous medical history (including any operations and dates) ......

Medication...... Supplements......

How many courses of antibiotics have you had in the last 5 years?......

Are you allergic / intolerant to any foods or medications? ......

......

How much exercise do you take?......

DIET –briefly an average day

Breakfast...... Lunch...... Dinner...... Snacks...... Daily water intake ...... tea/ coffee ...... Weekly alcohol ......

Do you smoke? ...... How many per day ......

Please tick if you suffer or have suffered from any of the following:

Cardiac disease / Hypertension
Stomach ulcers / Fissures / fistulas
Long term steroids / Liver disease
Kidney failure / Abdominal or inguinal hernia
Recent rectal / bowel surgery / Cancer treatment in last 5 years
Bloating / Flatulence / Indigestion
Acid reflux / Abdominal pain / Stress
Haemorrhoids / Rectal bleeding / Food poisoning
Migraines / Skin conditions / Bladder problems
Regular diarrhoea / Regular constipation
Anti depressents / Antacids / laxatives

How frequently do you have a bowel movement?......

Any problems?......

Ladies:

Are you pregnant? ...... How many weeks ......

Do you have any problems with your periods ......

Do you suffer from / or have suffered from ? (please give details)

Vaginal thrush ...... Cystitis ...... Endometriosis ...... Infertility ...... Miscarriage...... Hysterectomy ......

Any other gynaecological problems? ......

Do you take? HRT...... contraception ......

Gentlemen:

Do you suffer from prostate enlargement / prostitis? ......

Any other information: ......

......

CONSENT TO TREATMENT
I consent to a colon hydrotherapy treatment, the procedure has been explained to me and I have disclosed any relevant medical history which may affect my treatment.
Signed:
Date:

All information is strictly confidential.

Clare Barkway, Guild registered therapist, RMN RGN www.thecolon.co.uk