HEALTH HISTORY

PLEASE PRINT                                     DATE: _________________
 

NAME: __________________________________________________

CONTACT #'S:

(_____) _____ - ________ (HOME)

(_____) _____ - ________ (OFFICE)

(_____) _____ - ________ (CELL)

ADDRESS ___________________________________________

CITY: ___________________________________ STATE: ____

ZIP CODE: ____________

E-MAIL: ____________________________________________

HOW WERE YOU REFERRED HERE?

_____________________________________________________

OCCUPATION: ____________________ HOW LONG? ________

AGE ______ HEIGHT ________ WEIGHT _______

BIRTH DATE ______________________________

REASON FOR VISIT:

__________________________________________________________



 



 

PLEASE CHECK IF YOU HAVE
EVER HAD ANY OF THE FOLLOWING:

___ Cancer (where/when) _______________
___ Crohn's Disease/Colitis/Diverticulitis  
___ Severe Cardiac Disease
___ Aneurysm
___ Severe Anemia
___ GI Hemorrhage/Perforation
___ Severe Hemorrhoids
___ Cirrhosis
___ Fissures/Fistuals (colon)
___ Abdominal Hernia
___ Recent Colon Surgery
___ Renal (Kidney) Insufficiency

List Surgeries (When/What) ___________________________________

___________________________________________________________

___________________________________________________________

List Current Medications & Supplements:

Name                                           For What?

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

_______________________      _________________________________

Is there anything else that we should know about you?

___________________________________________________________

___________________________________________________________

IN CASE OF AN EMERGENCY, WHOM SHOULD WE CALL?

Phone Number (_____) _____ - ________ Relationship _______________

HAVE YOU BEEN DIAGNOSED WITH ANY ILLNESS
LIKE DIABETES, ARTHRITIS, HEART TROUBLE,
CIRCULATORY, RESPIRATORY, ETC?

___________________________________________________________

___________________________________________________________

PEASE CHECK if currently do/have:

___ Alcohol Use
___ Chronic Depression
___ High Blood Pressure
___ High Cholesterol
___ High Blood Sugar
___ Chronic Fatigue
___ Burning Stomach
___ Burning/Itching Anus
___ Coated Tongue
___ Constipation
___ Laxative Use _____
___ Diarrhea
___ Swollen Ankles
___ Difficulty Sleeping		 ___ Smoke
___  Chronic Stress
___ Allergies
___ Headaches
___ Asthma/Bronchitis/Upper Respiratory
___ Arthritis
___ Gas with foul odor
___ BM Painful/Difficult
___ Indigestion/Heartburn
___ Vomiting
___ Bloating
___ Skin Problems
___ Other _______________
___ Other _______________

BOWEL MOVEMENT FREQUENCY

___ One or more times per day w___ w/o___ laxatives.
___ Two - Three times per week w___ w/o___ laxatives.
___ Once per week
___ Two - Three times per month

Do you strain? _____ Rectal Bleeding? _____ Hemorrhoids? _____

Do you use fiber? ______ What Kind? ______________________
          
EVER HAD :

Barium Enema ______ year ________
Colonoscopy   ______ year ________
Colon Surgery ______ year ________
Rectal Surgery ______ year ________

 

ABOUT DIET & EXERCISE

HOW OFTEN DO YOU CONSUME THE FOLLOWING FOODS
PER WEEK

___ Protein w/ Starches @ Meals
(i.e. meat w/ potatoes and/or bread)
___ White Flour Products
(bread, cakes, etc.)
___ Fast Food
___ Restaurants
___ Packaged Dinners
___ Red Meat
___ Late Night Snacks
___ Soft Drinks
 		 ___ Fish
___ Milk
___ Cheese
___ Sugar Free/Fat Free Products
___ Multi-Grain Products/Cereal
___ Fresh Fruit (Raw)
___ Fresh Vegetables (Raw)
___ Canned Fruits/Vegetables
___ Coffee/Tea
___ Bottled Water
 

HOW OFTEN DO YOU EXERCISE?

___ Daily
___ 2-3 times per week
___ Once a week		 ___ 2-3 times per month   
___ Presently Incapable
 

TYPE OF EXERCISE

___ Walking, casual
___ Walking, power
___ Jogging/Running		 ___ Aerobics
___ Weight Bearing/gym work
___ Yoga/Stretching

WHAT MEASURES DO YOU TAKE TO REDUCE STRESS?

___ Exercise/Sports
___ Hobbies
___ Recreational Activities
___ Supplements/Prescriptions		 ___ Spiritual/Mental Work
___ Meditation
___ Reading/Writing
___ Performing Arts

HAVE YOU EVER DONE ANY CLEANSING, FASTING OR
DETOXING BEFORE? _______________________________

ANY MIND/BODY CONNECTIVE WORK? _____________

WHAT ARE YOUR HEALTH GOALS?

___________________________________________________________

___________________________________________________________

___________________________________________________________

 

ASIDE FROM YOUR PRIMARY CARE PHYSICIAN

DO YOU WANT HEALTH & NUTRITIONAL ADVICE? _______
IS WEIGHT MANAGEMENT AN ISSUE WITH YOU?    _______
DO YOU WANT TO LOWER YOUR CHOLESTEROL?  _______
DO YOU NEED HELP WITH STRESS MANAGEMENT? ______

ARE THERE ANY OTHER TARGETED AREAS OF HEALTH
YOU WANT ASSISTANCE WITH, THAT YOU ARE NOT
OTHERWISE GETTING FROM YOUR MEDICAL DOCTOR?

___________________________________________________________

___________________________________________________________

___________________________________________________________

Why have you chosen to have Colon Hydrotherapy,
Health and Nutritional Counseling?

___ 9th Amendment Right to Self Prescribe
___ Doctor Referral: Whom? ___________________________________

Do you have insurance? If yes, with whom?
__________________________________________________
If you are interested in filing, please ask for details.

Are you currently under a doctors care? Whom? _____________________
and for what are you being treated? _______________________________

If you are Federal, State or Local Agent upon entering YOU MUST DECLARE same or under THE BIVENS ACT - ARTICLE 42 OR BE HELD PERSONALLY & INDIVIDUALLY LIABLE