intake form (original) | Colonics Colon Care Hydrotherapy Colonic Irrigation Jacksonville Florida

Name *

Email *

Phone *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

How were you referred here? *

Occupation *

How Long? *

Age *

Height *

Weight *

Birthday *

Reason for visit: *

Please check if you have ever had any of the following:

Cancer (where/when)Crohn's Disease/Colitis/DiverticulitisSevere Cardiac DiseaseAneurysmSevere AnemiaGI Hemorrhage/PerforationSevere HemorrhoidsCirrhosisFissures/Fistuals (colon)Abdominal HerniaRecent Colon SurgeryRenal (Kidney) Insufficiency

List Surgeries (When/What)

List Current Medications & Supplements:

Please list the name and for what reason.

In case of and emergency, whom should we call? *Please list the name, phone number and relationship.

Is there anything else that we should know about you?

Have you been diagnosed with any illness like diabetes, arthritis, heart trouble, circulatory, respiratory, etc? *

PLEASE CHECK if you currently do/have:

Use AlcoholChronic DepressionHigh Blood PressureHigh CholesterolHigh Blood SugarChronic FatigueBurning StomachBurning/Itching AnusCoated TongueConstipationLaxative UseDiarrheaSwollen AnklesDifficulty SleepingSmokeChronic StressAllergiesHeadachesAsthma/Bronchitis/Upper RespiratoryArthritisGas with foul odorBM Painful/DifficultIndigestion/HeartburnVomitingBloatingSkin ProblemsOtherOther

Bowel Movement Frequency *

One or more times per dayTwo - Three times per weekOnce per weekTwo - Three times per month

Do you use laxatives? If so how often? *

Do you strain? *

YesNo

Rectal Bleeding? *

YesNo

Hemorrhoids? *

YesNo

Do you use fiber? What Kind? *

Ever had:

Barium EnemaColonoscopyColon SurgeryRectal Surgery

If you have had any of the above what year?

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?

Type of exercise

Walking, casualWalking, powerJogging/RunningAerobicsWeight Bearing/gym workYoga/Stretching

What measures do you take to reduce stress?

Exercise/SportsHobbiesRecreational ActivitiesSupplements/PrescriptionsSpiritual/Mental WorkMeditationReading/WritingPerforming Arts

Have you ever done any cleansing, fasting or detoxing before? *

YesNo

Any mind/body connective work? *

YesNo

What are your health goals?

Aside from your primary care physician

Do you want health & nutritional advice?

YesNo

Is weight management an issue with you?

YesNo

Do you want to lower your cholesterol?

YesNo

Do you need help with stress management?

YesNo

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?

Please list who referred you?

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? *

What are you being treated for?

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

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