4balanceandhealth

Colon Hydrotherapy Intake Form

Awaken Colonics and Wellness
Patient Information

Please complete all information accurately
Name*

TitleFirst NameLast Name
Birth Date*

DayMonthYear
Gender*
E-Mail*

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.
Occupation (if applicable):
How did you hear about Awaken Colonics?
Name of Referrer (If Applicable):

First NameLast Name
Work Status:

EmployedSelf-EmployedRetiredUnemployed
Do you have children?

No1 Child2 Children3 or more children
Marital Status:

SingleMarriedDivorcedSeparatedDomestic partnerWidowed
Medical History

Please complete all information accurately
Date of most recent visit to a Primary Care Physician (PCP)
Are you currently receiving healthcare by a MD/ND/Homeopath doctor (s)? If so, please explain: (Blood Sugar or Thyroid issues, High Blood Pressure or Cholesterol issues, etc.)
Do your records need to be shared with others? If yes, Whom?
Is Colon Hydrotherapy part of a protocol that a doctor or other healthcare professional has referred or Prescribed for you?
Doctor’s Name
When
Type of doctor

PCPGastroenterologistProctologistOther
Why?
Outcome
Have you had a colonic before?

YesNo
If yes, was it:
If yes, please describe your experience?
Type of device used (Colonic system) circle all that applies.

Closed SystemOpen SystemGravityNot Sure
Other forms of cleansing you are currently using or have used?
Do you have a bowel movement?

WeeklyEvery 2/3 DaysDaily2/3 Times a Day
Does it require straining?

YesNo
Does it feel unfinished?

YesNo
Is it spontaneous and effortless?

YesNo
Describe the amount and appearance.
Color:
Other:
Do you use a stool softener or laxative? Herbal or Suppository?
If yes, used for how long (days, months, years)?
Product name(s):
Do you have hemorrhoids or other rectal problems (itching, fissures, etc.)?
If yes, please describe?
if yes, have you been seen by a doctor?

Exercise: Describe your regular routine in the table below

	Frequency	Duration	Duration	Any thoughts?
Type
movement

Energy: On a scale from 1 to 10 where 1 = "can't get out of bed" and 10 = "optimal energy"

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Any relation to food and drinks?
Diet: What type of diet best describes your general dietary habits?
Diet: What type of diet best describes your general dietary habits?

junk food/fast food eatercombination (from junk food to health consciousvegetarianvegan raw macrobioticnatural food eater (over 50% organic)health conscious
How many servings of fruits do you eat per day?
How many vegetables do you eat per day? Raw or Cooked?
How much dairy do you consume per day?
How much meat do you eat per day or week?
Dietary Goal: My diet goal is to be

Combination (from junk food to health conscious)VeganHeath consciousNatural food eater (over 50% organic)I need help making changesI want a nutrition consultation to help make changes.
Water: How much do you drink a day? Glasses or Ounces
Water Source:

Tap (from city or well)BottledFilteredBoiledDistilledWhatever is available
Check the statements that apply to your eating habits and lifestyle:

I have a balanced dietI drink 8 glasses of water a dayI exercise enoughI do not exercise enoughI don't consume dairy productsI don't eat wheat/glutenI eat salads/vegetables/raw foodsI take laxativesI smoke and drinkI chew thoroughlyI eat quicklyI eat ready mealsI snack on sweets/chocolateI often overeatI have big meals after 8pmI often eat bread/pasta etc.I often take antibiotics
Stress: On a scale from 1 to 10 where 1 = "mellow" and 10 is "stressed out"

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What are your main sources of stress?
Do you notice changes in your bowel habits when you make any changes to exercise, diet, water intake, and stress? If so, please explain
For women premenopausal: Monthly cycle: Do you experience PMS? And are your periods more than 6 days? Are you susceptible to chronic yeast infection?
Reasons for the treatment (Please check all that apply):

Kick-start Healthy LivingDetoxIncrease EnergyHelp with Weight LossIrregular Bowel MovementsConstipationIBS/BloatednessDiarrhoeaLack of EnergyFood CravingsMood SwingsYeasts/CandidaSkin ProblemsAllergiesParasitesHeadaches/MigrainesMental HealthCleansingFertility
Have these conditions lasted for:

Less than 1 yearOver 1 year2-3 years5 years or longer
Allergies: List all known
Parasite: Do you know you have parasites? If yes, please describe:
Back Issues: Do you have any problems/ pain in the lower back (lumbar region)? If yes, please describe
How is your digestion?

AdequatePoorAcid RefluxBloating Burning/pain in stomachIndigestionUlcersOther
Do you take digestive aids? If yes, please describe:
When was the last time you took antibiotics? If yes, please describe
Please check if you had any of the following:

Recurring inflammatory bowel disease episodes (Generally, more than 3 episodes in a year or within 3 months of a flare up)Highly anxious, stressed or emotionalJoint Replacement (hip, shoulder, knee)Severe underweight or eating disordersSevere anaemiaFainting (vaso-vagal attack)ThrushHepatitisBloatingCandidaOther
Have you seen a doctor about them?
Please check whether you have any of the following conditions for which this treatment is contraindicated:

Abdominal HerniaActive Fissure (Tear or crack in the anus, usually very painful when active)Active Inflammatory Bowel Disorders - Ulcerative Colitis, Crohn's, Colitis and Diverticulitis (if medicated with drugs such as Sulfasalazine and Azathioprine, and if controlled and not having flare ups, do not tick this box)Active rectal fistula (Caused by an abscess "tunnelling into the rectum" sometimes requiring surgery)Anti-coagulants (If use of Warfarin, or a treatment dose of an injectable anti-coagulant (eg: Daltaparin, Tinzaparin)Autonomic dysreflexia (occurs in spinal injuries at or above T6)Bowel obstruction (eg: adhesions, volvulus, tumour etc...)Carcinoma of the colon or rectumChemotherapy (colonic can be performed after a minimum of 3 months once blood levels return to normal)Diabetes - Uncontrolled risk of hypoglycaemia during a treatmentEpilepsy - Uncontrolled risk of seizure during a treatmentHeart failureHypertension (unless medically controlled and under medication)Inflamed haemorrhoids (piles)Intussusception (the bowel "telescopes" on itself)Liver function ( Any condition that affects the liver and decreases its function needs to be assessed and if under the care of a medical professional)Pregnancy (risk of miscarriage)Radiotherapy of abdominal area not discharged from medical care (Radiotherapy burns and damages other tissues as well as the tumour, therefore risk of perforation. Colonic cannot be performed for 2 years after radiotherapy)Recent abdominal Surgery, laparoscopic or open - 3 to 6 months depending on the severity of the surgery and on medical discharge with no complicationsRecent bowel biopsy (3 months)Recent prostate biopsy made through the bowel (3 months)Recent laparoscopic investigation (6 weeks and on medical discharge)Recent surgery of colon or rectum (6 months)Renal insufficienciesRectal bleedingReduced kidney functionTight sphincterUndiagnosed persistent diarrhoea
Cigarette Intake:

Never smokedDo not smokeTrying to Quit0-5 a day5-10 a day10-20 a dayOver 20 a dayOther
Alcohol Intake:

Never drankDo not drinkOccasionallyBinge DrinkingEvery Day
General Stress Level:

LowModerateHigh
What therapies do you use regularly?
Blood Pressure: (for practitioner only)
Please add any information on operations/surgeries in the last 5 years
Medications and nutritional supplements used on a daily basis;
Time

Hour Minutes

AM/PM Option
Breakfast:
Time

Hour Minutes

AM/PM Option
Lunch:
Time

Hour Minutes

AM/PM Option
Dinner:
Snacks:
What is your ultimate goal for today’s visit and future sessions?
Colonic Irrigation Treatment Consent Form
PLEASE READ CONTRAINDICATIONS***

Absolute contraindications prohibit treatment altogether. For example, colon hydrotherapy is absolutely contraindicated for patients with rectal bleeding. The following are absolute contraindications for colon hydrotherapy, and it is NOT advised. Once they have subsided or been eliminated, colon hydrotherapy may be indicated.

Abortion (less than 6 months), Anal Fissure/Fistula (a tear in the colon), Anemais (Severe), Aneurysm, Cirrohosis, Colon Cancer (see below), Colon Surgery (less than six months post-op: see below), Colostomy, Crohn's disease (in the acute inflammatory or bleeding stages) Epilepsy, GI Hemorrhage/Perforation, Heart Disease (Severe, Uncontrolled Hypertension; Congestive Heart Failure) Hemorrhoids (severe or bleeding [minimal bleeding is okay]) Hernia (abdominal/inguinal) History of seizures, Kidney Dialysis, Miscarriage (less than 6 months) Pregnancy, Recent heart attack, Rectal Bleeding (except for minor hemorrhoids) Renal Insufficiency Tumor in the Rectum or Large Intestine, Ulcerative Colitis (active or bleeding) The following are relative contraindications for colon hydrotherapy. A physician's prescription is necessary. Crohn's disease, Acute Colitis, Severe Diverticulitis/Acute Diverticulitis, Colon Cancer (need MD approval on the integrity of colon), Colon Surgery (need approval on the integrity of colon.
I confirm that I have provided, to the best of my knowledge and ability, the relevant information about my health and lifestyle.

I agree to receive Colon Hydrotherapy from Breanna Burling at AwakenColonics and Wellness LLC and to inform my therapist of any relevant changes in my health and lifestyle. I have understood the treatment that I am consenting to and confirm that I have no reason to consult with my GP before undergoing the treatment.

**Reminder: Please stop eating 3 hrs prior and stop drinking 1 hour prior to your appt**
Signature*

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RELEASE STATEMENT:

I acknowledge that AWAKEN COLONICS AND WELLNESS LLC and its staff are not medical doctors. I understand that staff members may provide nutritional and other health-related information to help me attain the best health. All suggestions are designed to help me move towards my best state of health through personalized recommendations in lifestyles, exercise, health habits, and advanced nutrition. I understand that staff members of AWAKEN COLONICS AND WELLNESS LLC do NOT diagnose, treat, or claim to cure any illness or disease.

I have been made aware of all contraindications for colon hydrotherapy and am here on this day and any subsequent visit by my choice and solely on my behalf. I hereby release and discharge the staff of AWAKEN COLONICS AND WELLNESS LLC from any and all claims that my agents or I ever had, now have, or may have relating to or arising out of services provided or recommendations that have been received. I acknowledge that it is my responsibility to consult with my physician or other healthcare 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 providing service for my care,

I have read this informed consent and understand it. I am not a minor (under the age of 18)

I am signing this release voluntarily.
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Colon Hydrotherapy Intake Form

Patient Information

Medical History

Colonic Irrigation Treatment Consent Form