Colon Hydrotherapy Questionnaire

Colon Hydrotherapy

Wellness
Please complete the following, noting all symptoms which you have or have had, within the past year. Be as thorough as possible. Your information is confidential.
Your Appointment Date

MonthDayYear
Full Name*

First NameLast Name
FemaleMale
Age*
Birth Date*

MonthDayYear
Guardian's information, if client is a minor:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Height*
Weight*
Marital Status
Occupation and level of stress (10 being the highest level):*
Referred By:*
Blood Pressure

top numberbottom number
How much water do you drink, daily (cups /ounces /ml)?*
What kind/type of water do you drink? (eg. bottled, mineral, tap, alkaline, distilled, R.O.)*
3 times, daily2 times, daily1 time, daily2-3 times, weekly1 time, weeklyOther
Explain 'other'
What kinds of foods, liquids, and snacks do you consume, daily? *
Allergies (food, environmental)ChillsDepressionFaintingFeverForgetfulnessHeadachesUnexplained weight lossNervousnessOverweightSweatsNONE
Difficulty BreathingChronic CoughSpitting up BloodSpitting up PhlegmNONE
High Blood PressureLow Blood PressurePain over HeartPoor CirculationRapid HeartbeatSlow HeartbeatStroke/Heart AttackSwelling of AnklesNONE
Belching or GasBloody StoolsColon TroubleConstipationDiarrheaDifficult DigestionExcessive HungerGall Bladder issuesFood AllergiesHemorrhoids/PilesIntestinal WormsJaundiceLiver TroublePoor AppetiteRectal BleedingDistention of AbdomenNONEPain in Abdomen
Specific Conditions
AlcoholismAnemiaAnorexia or BulimiaAnxiety attacksAppendicitisArteriosclerosisArthritisAsthmaBleeding DisordersBronchitisCancerChemical dependencyColitisDiabetesDiphtheria or Whooping CoughEczemaEmphysemaEpilepsyFluGoiterGonorrheaGoutHeart problemsHepatitisHerniaHerpesKidney problemsHigh CholesterolHIV Positive / AIDSLupusMalariaMental disordersMigrainesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPanic attacksPleurisyPneumoniaPolioPsychiatric careRheumatic FeverSmall PoxStrokeThyroid problemsTonsillitisTuberculosisUlcersVenereal infectionNONE
FOR MEN ONLY
Blood / Pus in UrineProblems Controlling UrineFrequent UrinationKidney TroublePenal SoresProstate Trouble
FOR WOMEN ONLY
Cramps or BackacheExcessive Menstrual FlowHot FlashesIrregular CycleLumps in BreastMenopausal SymptomsMiscarriagePainful Menstrual PeriodsVaginal DischargeVaginal Sores
Absolute Contra-indications for Colon Hydrotherapy

We cannot provide treatment.
Severe or bleeding hemorrhoids – (not painful or bleeding are fine)Undergoing kidney treatment (dialysis) or you have only one functioning kidneyCirrhosis of the liverPregnancy – no treatment during the 9 monthsAbdominal herniaRecent colorectal surgery – (GP referral fine after healing is complete)None
Contra-indications for Use of Colon Hydrotherapy

The following contra-indications require a doctor's written authorization for colon hydrotherapy. Check all that apply or select 'None'.
Abdominal surgeryAbnormal mass or distentionsAcute Liver FailureAnemia (severe)AneurysmCardiac Condition or DiseaseCrohn's DiseaseColitisDiverticulosisFissures or FistulasHemorrhagingHemorrhoid surgeryLupusRectal surgeryRenal InsufficiencySevere HemorrhoidsIntestinal PerforationCarcinoma (cancer) of the RectumCongestive Heart FailureDigestive Problems (history)NONEHigh or low blood pressure not controlled by a doctor
AlcoholTea or CoffeeTobacco or MarijuanaMinerals and/or VitaminsHerbsPrescriptionsNone
Have You Ever Had/Been:
Surgeries? Please provide the dates and type(s) of surgery.*
An unusual accident or fall? Please provide the date and describe the situation.
Bone Fractures? Please provide the date and area of fracture.
Knocked unconscious? Please provide the date(s) and describe the situation.
Daily Habits
SLEEP - Number of hours? Is it enough?*
EXERCISE? How many times, weekly?*
FRESH AIR? How many times, weekly? Is it enough?*
SUNLIGHT? Is it enough?*
YesNo
Your Health Goal or Concern at this Time
What is your present health goal or concern?*
Medication names and reason for taking them. If none, type NONE:*
Supplements you are currently taking. If none, type NONE:*
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By typing my name, here, I acknowledge that I have read the contraindications and state that I DO NOT HAVE any of the listed conditions. I am aware that the use of colon hydrotherapy is by my own choice and that the colon hydrotherapist is not a medical doctor nor portrays herself as such. Colon hydrotherapy has not been clinically tested to provide any medical benefit. LawsOnHealth Wellness makes no claim that colon hydrotherapy will cure any condition or disease.*
Today's Date

MonthDayYear
Option to attach doctor's prescription or other document.

Upload a File

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The privacy of your information is important, and we will protect it. We will not use or disclose your information for any purpose not listed below, without your specific written authorization. Any authorization you provide may be revoked at any time by writing to us. We may provide medical information about you to health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information accompanying the bill may include your dates of service.*
Signature
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Colon Hydrotherapy

Specific Conditions

FOR MEN ONLY

FOR WOMEN ONLY

Absolute Contra-indications for Colon Hydrotherapy

Contra-indications for Use of Colon Hydrotherapy

Daily Habits

Your Health Goal or Concern at this Time

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