Colon Hydrotherapy & Informed Consent Form

SOUTHTOWNS COLON HYDROTHERAPY, LLC
DBA GO TO WELLNESS CENTER

COLON HYDROTHERAPY HISTORY & INFORMED CONSENT FORM
Client Information
Full Name
Date of Birth

MonthDayYear
Date
Age
Sex
Address
Phone Number
Email
example@example.com
Occupation
Emergency Contact
Primary Care Physician
How did you hear about us?
General Health History

Please click "yes" or "no"
Under care of a physician?

YesNo
Explain:
Hospitalized before?

YesNo
Explain:
Mental health concerns:

AnxietyDepressionBipolar DisorderPanic AttacksPTSDOther
Allergies

Please list your allergies as they pertain to each category.
Medication Allergies:
Food Allergies:
Environmental Allergies:
History of anaphylaxis?

YesNo
Gastrointestinal & Abdominal Health
Check all that apply.

Diverticulitis/DiverticulosisUlcerative ColitisCrohn's DiseaseIBSChronic ConstipationChronic DiarrheaHemorrhoidsAnal FissuresRectal BleedingPolypsObstruction/NarrowingAbdominal HerniaSevere Abdominal PainColon Cancer HistoryStomach/Intestinal Ulcers
Explain:
Bowel Habits
Frequency:

DailyEvery Other DayFew Times Per WeekOnce Per WeekOther
Symptoms
Check all that apply.

Hard StoolLoose StoolMucous in StoolFoul OdorDark StoolsLight StoolsGas/BloatingCrampingPainful Bowel Movements
Dark circles under eyes?

YesNo
Mucous discharge? (not in stool)

YesNo
Additional Concerns:
Surgical & Medical History
Abdominal/pelvic surgery?

YesNo
If "yes," what were the dates of the procedure/surgery?
Colon surgery/resection?

YesNo
History of:

Kidney DiseaseHeart DiseaseHigh Blood PressureLow Blood PressureLiver DiseaseSeizure DisorderDiabetesAutoimmune DiseaseThyroid Disease
Explain
Personal History (Optional)

Check all that apply
Have you experienced any of the following?

Emotional AbusePhysical AbuseSexual AbuseTrauma from medical procedures?
Explain:
Current Medications
Prescription Medications & Dosages:
OTC Medications/Supplements & Dosages:
Using:

Blood ThinnersDieureticsAnti-inflammatories/SteroidsRegular laxitives
Lifestyle Factors
How much is your daily water intake?
Fiber Intake:

HighModerateLow
Alcohol Use:

NeverRarelyModeratelyDaily
Smoking:

NeverTobaccoMarijuanaOther
When was your last bowel movement?
Contraindication Screening
Not permitted today if any apply.

PregnancyActive DiverticulitisActive Crohn's/Colitis FlareAbdominal HerniaSevere HemorrhoidsRectal BleedingColonoscopy w/ Biopsy <7 DaysAbdominal/Pelvic Surgery <9 MonthsUncontrolled Blood PressureHeart FailureKidney FailureInfection/FeverSevere Dehydration
Procedure Information

Please click to "initial" the form stating that you are aware.
Gentle water infusion explaination understood
Sterile speculum used
Possible pressure/gas/cramping acknowledged
Results vary/not guaranteed
Multiple sessions may be recommended
Not a substitute for medical treatment
Will notify staff of discomfort
Risks & Side Effects
Common temporary effects:
• Cramping
• Gas/bloating
• Fullness
• Mild nausea
• Lightheadedness or fatigue
Aftercare Information
I understand:
• Extra hydration is recommended
• I may feel lighter or fatigued
• Probiotics/fiber support may help
• Normal activities may resume unless advised otherwise
Optional Nutrition Support
Are you interested in a consult with our Registered Dietition?

YesNoMaybe later
Consent To Treat

Please sign below to accept the consent.
I consent to Colon Hydrotherapy at Southtowns Colon Hydrotherapy, LLC DBA Go To Wellness.
Signature

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Additional Client Declarations
Iblanks acknowledge the practitioner is assisting me
I understand the practitioner is NOT a medical doctor and will not diagnose, treat, prescribe.
I confirm I am not acting on behalf of any agency or investigator.
To the best of my knowledge:
• I am NOT pregnant
• I have NOT been diagnosed with Crohn’s, Diverticulitis, or Colitis
• I have NOT had abdominal surgery in the last 9 months
I understand Southtowns Hydrotherapy charges in full for missed or late-cancelled appointment
I understand late arrival may result in a shortened or rescheduled appointment without refund.
I acknowledge I have read, understand, and voluntarily agree to all statements.
Client Name:
Signature

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Date

MonthDayYear
Date
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SOUTHTOWNS COLON HYDROTHERAPY, LLC

DBA GO TO WELLNESS CENTER

Client Information

General Health History

Allergies

Gastrointestinal & Abdominal Health

Bowel Habits

Symptoms

Surgical & Medical History

Personal History (Optional)

Current Medications

Lifestyle Factors

Contraindication Screening

Procedure Information

Risks & Side Effects

Aftercare Information

Optional Nutrition Support

Consent To Treat

Additional Client Declarations