Colonic Patient Intake Form

2603 Oak Lawn Ave Suite 101 Dallas TX 75219
Ph. (214) 219-4100 www.deNovoHC.com
Todays Date

Month Day Year
Patient Information
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
How would you like to be addressed?
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Cell Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Patient E-Mail *
How would you like us to communicate detailed medical information? *
Current Occupation *
Emergency Contact *
Relationship to Patient *
Emergency Contact Best Phone Number *

Area Code Phone Number
Present Health
Please describe your health goals. What can we do to help you? *
Please check any of the following diagnosis that you may have *
Health History

A contraindication is a specific health condition in which a drug, procedure, treatment or surgery is inadvisable as it may be harmful to the health of the patient.
Contraindications, please check all that apply *
Describe what you typically eat
Breakfast
Lunch
Dinner
Snack
Do you eat meals at regular times?

Yes No
Do you eat between meals?

Yes No
Which is your biggest meal? *
How much water do you drink per day? *
Rate your digestion. *
Describe Bowel frequency
Bowel nature
Bowel movement associated with (choose those that apply).

Pain Blood Mucous Foul Smell
Do you take the following?

Probiotics Supplemental Dietary Fiber Laxatives
Are you currently under the care of a family physician or any other health professional? If yes, please tell us about it. *
Patient Medications

Be sure to include all medications, prescriptions, over-the-counter, dietary supplements and vitamins.

Please List All Medications

Medication Name

Dosage Amount

#Taken Daily

Ordering Doctor

Start Date

Any Drug/Medication Allergies? *

Yes No Unknown
List ALLERGIES and REACTIONS to Medications:

Name of Medication / Allergic Reaction 0/300
*I understand that my practicioner relies on the medication information I provide to him/her for my care and that any medication misinformation can result in hospitalization or death. I also understand that prevention of dangerous drug interactions and duplications of medications are a top priority for my safety. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete and I give permission for the facility to review my medication history.
Name *

First Name Last Name
Patient Tobacco/Alcohol/Caffeine Usage
Tobacco Usage: *

Yes, I Smoke Daily Yes, Sometimes I Smoke No, I Quit Smoking No, I Never Smoked
# Cigarettes per day? *
Date I Quit Smoking: *

Month Day Year
Total Years Smoking
Alcohol Consumption *

I don't drink 1-4 drinks/month 1-2 drinks/day 3-4 drinks/day 5+ drinks/day
Caffeine Consumption *

I don't use caffeine 1-4 cups/month 1-2 cups/day 3-4 cups/day 5+ cups/day
Please list anything else you would like us to know in order to help you achieve your goals.
Bowel Retraining Program

For Bowel Retraining we generally recommend daily Probiotic, supplemental Fiber and a colonic plan that includes a colonic on two consectutive days for two weeks (with only a very light meal in the evening between) and then once per week for 8 weeks.
I would also be interested to know more about: *

Botox Dermal Fillers Cool Sculpting Cool Tone Facial Skin Tighening Skin Care Facial Thread Lifting Thread Body Lifting Removing Sun Damage or Age Spots Bioidentical Hormones Hair Loss Sexual Health Laser Snoring Treatments Vaginal Rejuvenation Colonics Tattoo Removal Weight Loss Plastic Surgery Options Dental Care Financing Options
By my signature below I understand that this facility uses FDA approved Colon Hydrotherapy Devices. To date no studies have been conducted for this alternative and complementary modality. I am aware adverse events such as perforation, injury and illness have been alleged and claimed with the use of colon hydrtherapy services and enema kits. Should I experience discomfort or pain, I am responsible for immediately stopping my session.

I have reviewed and discussed the contraindications listed above with the medical staff and I do not have any adverse health concerns and I wish to proceed with my colon hydrotherapy session(s).

The ansers I have provided are true, accurate and complete to the best of my knowledge.
Signature
Should be Empty:

Patient Information

Present Health

Health History

Describe what you typically eat

Patient Medications

Patient Tobacco/Alcohol/Caffeine Usage