Name
*
First Name
Last Name
Email Address
*
Phone
(###)
###
####
Best time of day to reach you by phone?
Address
ZIP
Occupation
Date of Birth
Age, Height and Weight
Have you ever had a colonic or enema? If so, how long ago, how many and what was your experience like?
What are you reasons for wanting colonics / your health goals?
Are you currently under the care of a doctor or medical professional?
Please list all digestive troubles or discomforts you experience
What other health challenges / problems do you experience?
Anxiety and/or depression? If so, are have you been medicated for this?
Are you on any medications? Please list the names and what they are for.
Please list any supplements you take
How frequently are you having bowel movements?
Have you had a colonoscopy before? And were there any abnormal results?
How much water do you drink daily and what quality of water?
Please list any surgeries or traumas your body has ever been though.
What is your diet like? Please list what you typically eat and drink in a day
Do you/have you experienced any contraindications for colon hydrotherapy? (rectal/intestinal bleeding, gastrointestinal or rectal cancer, abdominal or rectal tumor, aneurism, history of seizures, acute diverticulitis, acute Crohn’s disease, ulcerative colitis, cardiovascular disease, uncontrolled hypertension, cirrhosis of the liver, intestinal perforation, severe hemorrhoids, fissures or fistula, kidney dialysis)
What are your health goals?
Women: Have you or do you use any form of birth control? What kind and how long?
What is stress like in your life from 1-10? What are your biggest stressors?
What changes do you want to achieve in your body and health?
What are the emotions you feel most often? What emotions would you prefer to feel most often?
Emergency Contact Name + Relationship
*
Emergency Contact Phone Number
*
