Name (*)
Email (*)
Title MrMrsMissMsDr
Address
Post code
Telephone
Mobile
Occupation
Age
Date of birth
Height
Weight
Does your weight vary much? Yes No
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
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?
Are you on any form of medication? NoYes
Name of medication
How long have you been taking it?
Do you take any vitamins or health supplements? NoYes
Name of vitamins/supplements taken:
Marital status SingleMarriedWidowedSeperatedRemarried
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? NoYes
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? YesNo
If yes, what are they?
Do you smoke? NoYes
If yes, how many a day?
What exercise have you done over the last month, including walking, dancing, gardening, etc?
Have you had any operations, including minor operations? NoYes
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.
