Colon Questionnaire

Please complete and submit questionnaire online if treatment required.

PERSONAL DETAILS


Name (*)

 

Email (*)

 

Title

 

Address

 

Post code

 

Telephone

 

Mobile

 

Occupation

 

Age

 

Date of birth

 

PHYSICAL DETAILS


Height

 

Weight

 

Does your weight vary much?
YesNo

 

MEDICAL HISTORY


Have you ever had, or do you currently suffer from any of the following? (please tick)
MigrainesAnaemiaHerniaHigh/low blood pressureAnal FissuresHay feverEczema/PsoriasisIBSAsthmaRheumatismColitisCystitisBack problemsArthritisHaemorrhoidsDiverticulitisUlcersDiabetes

 

CURRENT HEALTH


Do you experience any of the following? (please tick)
FlatulenceHeartburnIndigestionNauseaBloatingConstipationDiarrhoeaFaeces that seem to be a strong colourFaeces with a strong odourBlood or mucus in your faecesPain/difficulty having a bowel movementOther digestive problemsMucus/catarrhFrequent coldsCold soresCracked skinSensitive gumsThroat infectionsDizziness/light-headednessRunny or itchy eyesMouth 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 thingsSalty thingsCoffeeTeaNicotineChocolateAlcoholEnergy DrinksOther

 

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?

 

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.

 

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