Health Questionnaire

Important Information

Please fill in and submit this Health Questionnaire before attending your appointment. In the event that you aren’t able to complete this form ahead of your appointment, it will need to be completed on the day, which will impact your treatment time.

It is important to provide as much information as possible so that I am able to provide the best level of service to meet your requirements.

All answers are private and confidential.

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Prefix *

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Personal Details

Occupation

Date of Birth *

Age

Height

Weight

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Emergency Contact Details

Name *

Phone *

Email *

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Dependents

Do you have any dependents? *

How many dependents do you have? *

Name

Age

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Pets

Do you have any pets? *

Please provide details

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What is your main reason for seeking help through colonic hydrotherapy? *

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Medical History

GP Name *

GP Practice Address *

Address Line 1

Address Line 2

City

State

Zip Code

Have you suffered from high blood pressure? *

Blood Group (if known)

Do you have any current health complaints? *

Please provide details

Are you currently consulting any of the following? *

GP
Health Professional
Holistic Health Practitioner

Please select all that apply

Please provide details

Have you received any antibiotic or steroid-based treatment in the last six months? *

Please provide details, including the approximate date you stopped taking them.

Are you currently taking any other prescribed medication? *

Please provide details

Have you ever taken any of the following *

Recreational Drugs
Steroid-based Medication

Please select all that apply

Have you had any past medical problems / surgical procedures? *

Please provide details

How were you born

Were you

Have you ever been hospitalised, as a baby, child or adult for an infection that required antibiotics, particularly intra-venous antibiotic? *

Please provide details, including when and the duration of your stay.

Have you ever had enemas or colonic treatment before? *

Have you had any rectal problems in the past? *

Do you ever have any mucous in your stools? *

Does stress affect your bowel movements? *

What are your bowel-emptying habits? *

How often do you urinate during a day? *

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Procedures

Have you ever had any of these procedures? *

Colonoscopy
Endoscopy
Barium Enema
Abdominal Scans

Please select all that apply

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Contra-indications

Please tick if you suffer from, or ever have suffered from, any of the following conditions.

Please select all that apply.

General

Alcoholism
Amalgam Fillings
Amalgam Fillings
Cancer
Chronic Fatigue Syndrome
Diabetes
Dizziness
Double / Blurred Vision
Drug Addition
Fainting Spells
Ear Infections
Epilepsy
Headaches / Migraines
Hepatitis
HIV / Aids
Hypoglycaemia
Gallstones
M.E.
Over-active Thyroid
Under-active Thyroid
Weight Loss

Cardio-vascular

Angina / Chest Pains
Hardening of the Arteries
Low Blood Pressure
Rapid / Irregular Heartbeat
Swelling of the Ankles

Respiratory

Asthma
Bronchitis
Emphysema
Hay Fever
Sinus Problems
C.O.P.D

Muscle and Joint

Arthritis
Low Back Pain
Joint pain / Stiffness
Rheumatism
Muscle Weakness

Skin

Acne
Bruise Easily
Dermatitis
Eczema
Fungal Infections
Psoriasis

Gastro-intestinal

Abdominal Pain
Bad Breath
Colitis
Constipation
Cravings
Diarrhoea
Distension / Abdominal Bloating
Diverticulitis / Diverticulosis
Heartburn
Indigestion
Irritable Bowel Syndrome (IBS)
Liver Trouble (i.e. Fatty Liver, Cirrhosis )
Rectal Bleeding
Rectal Itching
Ulcerative Colitis

Genito-urinary

Bladder Infections
Kidney Infections / Stones
Kidney Failure

Emotional / Nervous System

Anxiety
Depression
Fatigue
Insomnia
Irritability
Lack of Concentration
Lethargy
Mood Swings
Over-reacting
Panic Attacks
Memory Loss

Women

Amenorrhea (absence of periods)
Dysmenorrhea (painful periods)
Endometriosis
Genital Herpes
Genital Warts
Heavy Menstrual Flow
Hysterectomy
PMT
Vaginal Thrush
Currently pregnant
Current taking the pill

What was the date of your last period

Men

Enlarged Prostate
Genital Herpes
Genital Warts

Please specify any other

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Lifestyle

How many hours do you sleep a night?

More than 8 hours
Less than 8 hours

How often do you exercise?

Every day
2-3 times a week
Not at all

How many cups of tea, coffee or water do you drink a day?

Tea

Coffee

Water

How much alcohol do you drink a week?

Do you smoke? *

How many a day?

If you no longer smoke, when did you stop?

Do you travel abroad frequently? *

Have you ever suffered from sickness and diarrhoea? *

Do you feel you are under a lot of stress at the moment? *

how would you rate the level of stress you’re feeling?

On a scale of 1 to 10 where 1 is not feeling stressed at all and 10 is feeling very stressed.

Do you know the cause?

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Diet

Please describe your current eating habits on an average day.

Breakfast

Lunch

Dinner

Snacks

Which foods do you avoid due to allergy or intolerance?

Are there any foods you believe do not suit you?

Which foods do you eat every day and could not give up?

Are you: *

Vegetarian
Vegan

Are you taking any vitamin / mineral supplements? *

Have you ever suffered from an eating disorder, including over-eating? *

Please provide details

Have you suffered with gastroenteritis or had any other gastric upsets? *

Please provide details

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Additional Details

Please provide any other relevant information

How did you hear about the Colonic Hydrotherapy Clinic? *

Please provide details

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the Men

Consent Form

I agree to an examination and colonic irrigation treatments.

To the best of my abilities, I have informed my therapist of any medical conditions, medication and surgery that could affect my treatment.

I understand that colonic irrigation is part of an overall approach to diet and lifestyle and is not a medical treatment.

The medical conditions that are contra-indicated with colonic irrigation are:

• recent surgery to the rectum or abdomen (less than 8 weeks)
• abdominal hernia
• severe haemorrhoids
• fissures
• fistulas
• bowel perforation
• cancer of the rectum or bowel

• blood pressure above 160/100
• pregnancy
• heart disease
• kidney disease
• severe anaemia
• severe or uncontrolled diabetes
• long-term oral steroid use.

I have informed my therapist of any possible latex allergy.

The information provided within this form is, to the best of my knowledge, true and accurate. I also confirm that I have not withheld any health or personal information that may affect the therapist’s decision to treat me with colon hydrotherapy.

I also agree to have a rectal examination, if during discussion, this is considered necessary.

I suffer from:

Diabetes
Angina
Epilepsy
Heart Disease
Other

Please provide details

In the event of an attack, I consent to the following action being taken:

Administer my medication
Call an ambulance
Call my emergency contact
Position comfortably
Other

Please provide details

Signature *

Clear Signature

Date *

All of the information within this form is for Colon Hydrotherapy Clinic purposes only and will not be shared with other companies.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

Download Pre-Consultation Health Questionnaire

If you would prefer you can download the health questionnaire below in order to complete before your appointment.

Please ensure that you bring this with you.

Download Now