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Homeopathy
Colon hydrotherapy
About
Contact
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Home
Homeopathy
Colon hydrotherapy
About
Contact
Book Now
Intake form
Colon Hydrotherapy
Email
This field is for validation purposes and should be left unchanged.
About You
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Alternate Phone
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
.
Occupation
About Your Visit
Have you had colonics before?
(Required)
Yes
No
How many?
When was your most recent one?
Other cleansing experiences
Name of your M.D., Herbalist and/or N.D.
What are your reasons for having colonics?
(Required)
Diet & Lifestyle
On a scale of 1 to 10, what is your stress level?
(Required)
Select one
1
2
3
4
5
6
7
8
9
10
1 = very low, 10 = very high
Blood type
Select one
A+
A−
B+
B−
AB+
AB−
O+
O−
Unknown
How would you describe your diet?
Omnivore
Vegetarian
Vegan
Other
If vegetarian or vegan, for how many years?
Do you eat eggs and dairy?
Yes
No
Approximately what percentage of your diet is raw foods?
Please enter a number from
0
to
100
.
How often do you consume: Poultry / Fish
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Red meat
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Dairy
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Eggs
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Flour products / Bread
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Caffeine
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Sugar
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Salt
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Artificial sweeteners
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Pop / Soft drinks
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
How often do you consume: Alcohol
Select one
Never
Rarely
A few times a week
Daily
Multiple times a day
Do you buy organically grown foods?
Yes
Sometimes
No
Do you smoke?
(Required)
Yes
No
Do you take any medications?
(Required)
Yes
No
Please list your medications
(Required)
Do you take Gabapentin?
(Required)
Yes
No
Do you take herbal and/or nutritional supplements?
(Required)
Yes
No
Please list your supplements
(Required)
Health Conditions
Do you have problems with any of the following?
(Required)
Constipation
Diarrhea
Abdominal pain
Hemorrhoids
Gas
None of these
How often do you have a bowel movement?
(Required)
Select one
Multiple times a day
Once a day
Every 2–3 days
Once or twice a week
Less often
Any other colon problems, now or in the past?
Have you taken any of the following in the past?
Antibiotics
Chemical laxatives
Birth control
None of these
Food allergies or food restrictions
Diagnosed health conditions
Have you been diagnosed with Hepatitis or HIV?
(Required)
Yes
No
If yes, which type?
(Required)
Do you have, or are you a carrier of, an infectious disease?
(Required)
Yes
No
If yes, what is it?
(Required)
Do you have a bleeding disorder?
(Required)
Yes
No
Do you have a heart condition?
(Required)
Yes
No
Contraindication Screening
Some conditions mean colon hydrotherapy may not be right for you. Please check every item that applies to you, now or in the past.
Please check all that apply
(Required)
Cancer of the colon or GI tract
Acute abdominal pain
Recent history of GI bleeding
Congestive heart failure
Uncontrolled hypertension
History of seizures
Epilepsy or psychoses
Abdominal surgery
Intestinal perforation
Fissures or fistula
Abdominal hernia
Vascular aneurysm
Renal insufficiency
Cirrhosis
Carcinoma of the rectum
Severe hemorrhoids (current)
Severe hemorrhoids (past)
Diverticulitis
Recent heart attack
General debilitation
Recent colon or rectal surgery
Pregnancy (current)
Pregnancy (past)
None of the above
For any past conditions or recent surgery checked above, approximately when?
(Required)
How did you hear about our office?
Doctor referral
Health care practitioner
Friend
Card / Flyer
Magazine
Internet
Other
Who referred you, or other details?
Anything else you would like us to know?
Confirmation
(Required)
I confirm the information provided above is accurate and complete.
