Please complete and submit questionnaire online if treatment required.

PERSONAL DETAILS

Name: *

Title:
Address:
Post Code:
E-mail Address: *
Telephone (Home):
Telephone (Mobile):
Occupation:
Age:
Date of birth:

PHYSICAL DETAILS

Height:

Weight:
Does your weight vary much?

MEDICAL HISTORY

Have you ever had, or do you currently suffer from any of the following? (please tick)

Migraines
Anaemia
Hernia
High/low blood pressure
Anal Fissures
Hay fever
Eczema/Psoriasis
IBS
Asthma
Rheumatism
Colitis
Cystitis
Back problems
Arthritis
Haemorrhoids
Diverticulitis
Ulcers
Diabetes

CURRENT HEALTH

Do you experience any of the following? (please tick)

Flatulence
Heartburn
Indigestion
Nausea
Bloating
Constipation
Diarrhoea
Faeces that seem to be a strong colour
Faeces with a strong odour
Blood or mucus in your faeces
Pain/difficulty having a bowel movement
Other digestive problems
Mucus/catarrh
Frequent colds
Cold sores
Cracked skin
Sensitive gums
Throat infections
Dizziness/light-headedness
Runny or itchy eyes
Mouth ulcers
How often do you have a bowel movement?
How many times do you empty your bladder?

MEDICATION

Are you on any form of medication?

Name of medication:
How long have you been taking it?
Do you take any vitamins or health supplements?
Name of vitamins/supplements taken:

FAMILY

Marital status:

FOOD

Please write down what you eat on a typical day, including quantity (Fresh fruit, Vegetables, Meat, Dairy produce, Water, Other drinks)

Are you allergic or intolerant to any food or drink?
If yes, which ones?:
Do you crave any of the following? (please tick)Sweet things
Salty things
Coffee
Tea
Nicotine
Chocolate
Alcohol
Energy Drinks
Other
Are there any foods you find hard to digest?:
If yes, what are they?
Do you smoke?
If yes, how many a day?

EXERCISE

What exercise have you done over the last month, including walking, dancing, gardening, etc?

HEALTH

Have you had any operations, including minor operations?

If yes, please state what the operation was, and when you had it.
What aspects of your health would you like to improve?
CONSENT

I consent to the treatment of Colon Hydrotherapy, the procedure has been explained to me and I have had the opportunity to ask questions.

I can confirm that this is a medical procedure being performed to help restore my-self esteem.

I confirm that the information given is complete and correct to the best of my knowledge. I also understand that I must inform my therapist of any changes in the above information before subsequent treatments.

* please tick here


* Required