Colonic Wellness Client Questionnaire

1

Colonic Wellness Client Questionnaire:

Name: ______Date______

Address: ______City:______

State: ____Zip: ______

Homephone:______Workphone:______

Cell phone: ______E-mail: ______

Place of Employment: ______Occupation: ______Date of Birth: _____/____/_____ Age:_____ # of Children:___ Ages: ______

Male ___ Female____ Blood Type:____ Height:____ Weight: ____ Eye color: _____ Hair color: _____

Spouse’s Name: ______Marital Status: S, M, D, W, other: __

How did you hear about us______Referred By:______

*In case of an emergency who do we contact? Name:______

Relationship: ______Phone # ______2nd Phone #______

MEDICAL HISTORY

Name of Physician: ______Physician’s Phone #______

Address: ______City: ______

State: ____Zip: ______

Are you pregnant? ______How far long? ______Or Are you trying to? ______

Major physical complaints:______

Are you currently under a physician’s care? ______if so, explain:______

______

Are you on medications? ______Please list them all:______

______

Do you take any vitamins, minerals, or herbal supplements? ______please list them:

1. ______... 2. ______3. ______4. ______

5. ______6. ______7. ______8. ______

List all known allergies: ______

Have you ever:

Had any surgery? Y/N When: ______Describe: ______

Been in an accident? Y/N When: ______Describe: ______

Any broken or fracture bones? Y/N When: ______Describe: ______

Had a Barium Enema? Y/N When: ______Describe: ______

Had a Sigmoidoscopy? Y/N When: ______Describe: ______

Had a Colonoscopy? Y/N When: ______Describe: ______

Had a Colon, Rectal or Gastrointestinal procedure? Y/N When: ______Describe: ______

Daily Routine:

How do you rate your stress in your life style? Circle best ( Light, Moderate , Heavy)

Can you relax easily? Y / N Are you easily excited or upset? Y / N

Do you exercise in a week? Y / N How often ______What Kind? ______

What do you do for recreation? ______

What do you do for relaxation? ______

HEALTH CONDITIONS

Please take your time review and circle all that apply currently ( c ) or in the past ( p ):

Abdominal pain______Anemia______Arthritis______

Arteriosclerosis ______Asthma ______Back pain ______Bloating______Blood clots______Bloody or black stools______Blood pressure-High______Blood pressure-Low______

Body odor______Bowel impaction______

Breast pain______Bronchitis______

Bruise easily______Cancer______

Candida______Change in stool______

Chest pain______Chronic cough______

Colitis______Crohn’s disase______

Constipation-recent______Constipation-chronic______

Depression______Diabetes______Diarrhea______

Diverticulitis______Dizziness______Double/blurred vision______

Ears ringing______Edema______Emphysema______

Enlarged thyroid______Fainting spells______Fatigue______

Family history of colon cancer______Feet-cold ______

Fistula or fissures______Foot numbness______Frequent headaches ______

Gallbladder disease______Gas______Hands-cold or numbness______

Heartburn______Heart condition______Heart disease______

Hemorrhoids______Hepatitis______Hernia______

Herniated disc______High cholesterol______

History of seizures______Irritable bowel syndrome______

Parasites______Restless Legs______Sleep Disorders______

Ulcerative colitis______Ulcers______Underweight______Overweight______Vaginal discharge______Varicose veins______

Colon Hydrotherapy:

Is a safe and effective method of cleansing your large intestine (colon). We do not

Diagnose diseases and/or prescribe medication. It is your responsibility to provide health information and to inform us of any change. Any and all information shared with you in this clinic is for educationalPurposes only.

Colon History:

Have you ever had colon Hydrotherapy? Y / N If yes, when _____/____/_____

How many? _____ How often? ______Where? ______

What do you hope to accomplish with your colonic session today? ______

How often do you have bowel movements? ______

How would you best describe your bowel movements? ______

Straining? ______With ease? ______Discomfort? ______

Explain discomfort? ______

Describe size and shape of your waste: (pellets, pencil, bFatigue

anana like?): ______

Have you ever had rectal bleeding? _____ If so, when? ______Did you see a doctor? ______

Do you have hemorrhoids or other rectal problems? ______

Do you use laxatives? Y / N How often? ______Which? ______

Dietary Habits:

Describe your intake of the following (please indicate Heavy(H) , Moderate(M), Light (L), None( N ). Tobacco______

Alcohol- ______Coffee_____ Soda______Tea______

Milk/Cheese/Butter______Fruits/veggies (canned) ______

Fruits/veggies (fresh) ____ Fruit/veggies (frozen) ______

Grains- ____ Oats______

White flour bread______Whole Wheat______

Milk/cheese/butter ____

Processed foods______Raw foods______

Meat (red) ____ Seafood/Shellfish______

Pork ____ Poultry______

Sugar______Sweets______

Circle which one best describe your diet (Standard American, Vegan, Vegetarian, Low carb, Raw? )

Where do you eat most of your meals? Home ___% Restaurant _____ %

How many glasses of water do you drink a day? ______

Do you fast or diet? Y / N if yes, how often?______

Colon Hydrotherapy Release

I understand and agree that Colon Hydrotherapy services provided by this state certified ColonHydrotherapist is provided pursuant to and in accordance with the laws of the state of California governingColon Hydrotherapy and that full and complete medical history disclosure is essential in providing suchtherapy. I agree to hold harmless, release and indemnify this state certified colon Hydrotherapist againstAny and liability arising from the application of Colon Hydrotherapy. By signing this release I herebyDeclare that I have provided to this Colon Hydrotherapist with all relevant information necessary for theproper application of Colon Hydrotherapy. I give my permission for this Colon Hydrotherapist to provideSuch therapy.

Signature: ______Date: _____/____/______

Services rendered are payable at time of service unless special arrangements have been made in advance ofyour session. For your convenience we accept visa, master card, debit check cards or cash.

Initial______

At Colonic Wellness We value you. Therefore, we are sure that you understand

Your time is as valuable as ours is.

To provide you with the best service, it is important for you to be on time for your appointment.

If you are running late, please call our center to let us know… and understand that we may need toreschedule your appointment.

If you are unable to make your appointment, we ask a 24 hour cancellation notice. If you areunable to give us a 24 hour cancellation notice, we reserve the right to charge you a $60. Cancellationfee. Or a forfeiture of a session in advanced

Signature: ______Date: _____/____/______

All Prepaid Packages are good for 1 Year from the date of Purchase.

I have read the above policy and except the terms

Signature: ______Date:______

I have not been diagnosed with any contraindications for colonic irrigation. I am aware that Colonic Wellness in the CaliforniaHealthCenter has a professionally trained I-Act Certified Therapist and is not a Physician, whom therefore cannot diagnose, prescribe, treat, and cure any disease. The client must insert his or her own disposable (Speculum) rectal tube. I am aware of adverse events such as perforation: injury and illness have been alleged and claimed with the use of colon irrigation and enemas devises. If during self-insertion of the disposable rectal tube there is resistance, or if I experience discomfort, pain, I am responsible for stopping and notify the therapist. This Center does not claim to treat any condition or disease.