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Colon hydrotherapy
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Home
Homeopathy
Colon hydrotherapy
About
Contact
Book Now
Intake form
Homeopathy
Name
This field is for validation purposes and should be left unchanged.
About You
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Age
(Required)
Please enter a number from
0
to
120
.
General Information
Have you ever seen a homeopath before?
(Required)
Yes
No
Please explain your experience and what was addressed
(Required)
What brings you in today?
(Required)
Main complaint or concern
Medical History
Have you ever been hospitalized?
(Required)
Yes
No
Please explain when and why
(Required)
Have you had any childhood illnesses?
e.g., measles, mumps, chickenpox
Do you have any allergies?
(Required)
Yes
No
Please list your allergies
(Required)
Vaccination history
Which vaccines have you received, as a child or adult?
Are you currently on any prescription medications?
(Required)
Yes
No
Please list your medications
(Required)
Include name, dosage, what time(s) you take them, and when they were last adjusted
Are you currently taking any supplements or vitamins?
(Required)
Yes
No
Please list your supplements
(Required)
Include name, dosage, and what time(s) you take them
Daily Habits
What time do you typically go to bed?
What time do you typically wake up?
Do you wake up during the night?
Yes
No
At what times?
What position do you usually sleep in?
Right side
Left side
Back
Stomach
Do you sleep with your feet:
Covered
Uncovered
Both
Do you feel rested after sleep?
Yes
No
Do you have vivid dreams or nightmares?
Yes
No
Describe briefly
Diet & Digestion
What time do you usually eat breakfast?
What time do you usually eat lunch?
What time do you usually eat dinner?
Do you eat quickly or slowly?
Quickly
Slowly
How much water do you drink daily?
Do you experience any of the following after eating?
Bloating
Gas
Burping
Acid reflux
None
How are your bowel movements?
e.g., frequency, consistency, ease
How often do you have a bowel movement?
Select one
Multiple times a day
Once a day
Every 2–3 days
Once or twice a week
Less often
Do you regularly drink any of the following?
Coffee
Tea
Alcohol
None
Have you ever smoked?
Yes
No
Explain briefly
Lifestyle & Preferences
Do you exercise regularly?
Yes
No
What type, and how often?
What kind of water do you drink?
Select one
Tap
Filtered
Spring
Distilled
Other
Do you prefer mountains or seaside?
Mountains
Seaside
Which climate do you prefer?
Hot
Humid
Dry & fresh
Do you prefer routine or change?
Routine
Change
Do you prefer being with people or alone?
Being with people
Being alone
Do you prefer sleeping in:
Cool, fresh air
A warm and cozy atmosphere
Would you describe yourself as:
A morning person
A night owl
Neither
Emotional Well-being
Have you experienced any major trauma in your life?
Yes
No
e.g., death of a loved one, accidents, abuse
Please share what you're comfortable with
Do you have any fears or phobias?
Yes
No
Please describe
Menstrual & Hormonal Health
Complete this section only if it applies to you.
Does this section apply to you?
(Required)
Yes
No
At what age did you begin menstruating?
Are your menstrual cycles regular?
Yes
No
How long do they last? (days)
How far apart are they? (days)
Describe any hormonal symptoms
e.g., mood swings, cramping
Have you ever used hormonal birth control?
Yes
No
Which type, and for how long?
Are you currently in menopause or perimenopause?
No
Perimenopausal
Menopausal
Do you experience hot flushes or other menopausal symptoms?
Yes
No
Please describe
How many pregnancies have you had?
How many births have you had?
Have you had any miscarriages?
Yes
No
How many?
Confirmation
(Required)
I confirm the information provided above is accurate and complete.
