Colon Therapy Screening
This form is for patients interested in Expedited Colon Hydrotherapy ONLY. In order to qualify, you must NOT have any major health issues or severe digestive problems. Once your form is submitted, we will review your request and contact you promptly.
Patient's Name
*
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Address
*
Preferred Location of Therapy
*
Raleigh
Wilmington
What condition do you hope to address by undergoing colon hydrotherapy?
*
Are you currently under care for this condition?
*
Yes
No
Explain the care that you are receiving
*
Do you have any of the following digestive disorders:
*
Repeated stomach pain
Heartburn
Indigestion
Gum problems
Change in appetite
Nausea or vomiting
Belching
Difficulty swallowing
Vomiting blood
Constipation
Black stools
Blood in stools
Diarrhea more than 3 days
History of inflammatory bowel disease
History of bowel surgery
Rectocele
None of these
Other
Do you have any of the following:
Any symptoms or history of colon or rectal disorders?
*
Yes
No
Please explain further
*
Any symptoms or history of upper GI disorders (reflux, gastritis, etc.)?
*
Yes
No
Please explain further
*
Any family history of colon polyps or colon cancer?
*
Yes
No
Please explain further
*
Any cardiopulmonary disease (heart disease, hypertension, etc.)?
*
Yes
No
Please explain further
*
Any neurological disease?
*
Yes
No
Please explain further
*
Any anti-coagulation medications?
*
Yes
No
Please explain further
*
Signature
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: