Cleanse by Trinity Health - Health Questionaire
Please complete this form before you come into the clinic, it really helps us to keep ontime and delivering excellent service.
Name
First Name
Last Name
Email
example@example.com
Cell Number
*
-
Area Code
Phone Number
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Your reason for choosing Colon Hydrotherapy?
I take the following medications
Hypertension Meds
Diabetes / Insulin Resistance Medication
Thyroid Medication
Other
Contraindications for Colon Cleansing. Are you currently experiencing or previously been diagnosed with any of the following?If you have one of the below conditions, please check with our office if you are eligible to colon cleansing.
Pregnancy
Liver or Kidney Disease
Anemia (severe, medicated)
Aneurism
Heart Conditions such as congestive heart failure or a heart attack
Uncontrolled High Blood Pressure
Pulmonary Embolism
Diverticulitis / Diverticulosis
Epilepsy / Seizures
Inflammatory Bowel Disease (Chrohns Disease, Ulcerative Colitis, Diverticulosis or similar)
Heamorrhoids
Fistulas
Prostitis
Cancerous Tumours
Carcinoma
Surgery - Recent Abdominal (within 6 months)
Epilepsy/Seizures
I have none of the above!
By selecting below, I acknowledge
*
I have read the above and do not have any of the contraindicated conditions.
I may have or do have a condition that requires me to have a prescription for the colonic treatment I have scheduled. I understand that my therapy will be rescheduled if I am unable to meet the above terms and conditions.
Surgeries - please list all
Were you referred by a doctor? If so please give his/her name.
Exercise
I exercise regularly 3 to 5 times a week
I am mildly active
I wish I could, I have no time
I hate exercise
My nutritional status
I eat extremely well
I think I eat well, but don't always make good choices
I am an emotional eater
I eat terribly (no judgement!)
My Bowel Movements
I have regular bowel movements (mostly)
I have bowel movements 2 to 3 times a day
I have bowel movements 2 to 3 times a week
I have bowel movements once a week or less
I have diarrhea
I alternate between constipated and diarrhea
Bloating
I am never bloated
I am sometimes bloated
I drink water and I bloat
I always feel 6 months pregnant
Indigestion and Heartburn
I never get heartburn or indigestion
I sometimes get heartburn or indigestion
I always get heartburn or indigestion
Your time is valuable and we appreciate your understanding that our time is valuable as well. If you don’t show up for your appointment or if less than 24 hour notice is given to change or cancel an appointment, you will be charged a fee 50% for the missed appointment. Your willingness to cover the cost of a missed appointment when you cannot give 24 hour notice clearly demonstrates your consideration of our time and efforts. (Special circumstances are considered on a case-by-case basis). Colon Hydrotherapy is NOT covered by Medical Aids. There may be supplements recommended to complement and enhance the process of cleansing, detoxifying, and re balancing the system. These supplements available are an additional cost. All payments are due at the time of visit. Preferred method of payment credit card, or cash. The above prices are subject to change. There may be times when promotional prices are offered. Packages must be used within 3 months from the time of purchase. Packages are NOT TRANSFERABLE or REFUNDABLE UNDER ANY Circumstance. Our price list is available here https://www.trinityhealthsa.com/price-list/IndemnityI acknowledge that Briony Botha and Cleanse by Trinity Health and all staff members are not medical doctors. I understand that Briony Botha and staff members of Trinity Health and may provide nutritional and other health related information to help me attain and maintain my best health. All suggestions are designed to help me move towards my best state of health through personalized recommendations in lifestyle, exercise, health habits, and advanced nutrition. I understand that Briony Botha as well as staff members of Trinity Health do NOT diagnose, treat, or claim to cure any illness or disease. I have been made aware of all contraindications (above) for colon hydro-therapy and am here on this day and any subsequent visit by my choice and solely on my own behalf. I hereby release and discharge Briony Botha and Trinity Health from any and all claims which I or my agents ever had, now have or may have relating to or arising out of services provided or recommendations that I have received. I acknowledge that it is my responsibility to consult with my physician or other health care providers relating to any disease or condition that I may have. I give permission to share my health information with other practitioners and health care professionals who are also providing services for my care should I request this information be shared. I hereby agree to the above terms and conditions. I acknowledge that by submitting this form I am giving my consent and acceptance.
I accept the terms and conditions
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