Pre-Screen for Colon Hydrotherapy
*CERTAIN ANSWERS MAY BE A CONTRAINDICATION AND COULD AFFECT AN OFFER FOR COLON HYDROTHERAPY
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
1. Are you 18 years or older?
*
YES
NO
2. Are you currently taking BLOOD THINNERS other than a low dose aspirin?
*
NO
YES
3. Are you currently taking DIURETICS OR WATER PILLS (*this includes SPIRONOLACTONE for acne) for hypertension or another condition?
*
NO
YES
4. Are you currently taking STEROIDS OR IMMUNOSUPPRESSANTS?
*
NO
YES
5. Do you have any conditions with your HEART, LIVER OR KIDNEYS?
*
NO
YES
6. Do you have an ABDOMINAL HERNIA OR ABNORMAL DISTENSION?
*
NO
YES
7. Do you have a diagnosed condition such as CROHN'S DISEASE, DIVERTICULITIS, COLITIS OR CANCER?
*
NO
YES
8. Are you currently PREGNANT?
*
NO
YES
9. Have you had any ABDOMINAL OR RECTAL SURGERY within the last 3 months?
*
NO
YES
10. Are you currently treating any ACTIVE HEMORRHOIDS, FISSURES/FISTULAS?
*
NO
YES
11. Have you had SEIZURES (PAST OR PRESENT) or FAINTING SPELLS?
*
NO
YES
12. Are you SEVERELY ANEMIC (*this indicates recent hospitalization, transfusions or long term untreated chronic symptoms due to anemia)?
*
NO
YES
13. Are you OXYGEN DEPENDENT or require PHYSICAL ASSISTANCE, i.e. walker, cane, scooter or wheelchair?
*
NO
YES
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