Colon Hydrotherapy Specific Questionnaire

Have you had colonics in the past______

If yes, how many______

How long ago______

Please tick the boxes if you have/had any issues with the following:

Spinal/back

/

Poor Digestion

/

Piles

Joints

/ Constipation / IBS
Eczema / Diarrhoea / Gas/Bloating
Varicose Veins / Chrons/ Diverticulitis / Headaches/migraines
Blood pressure / Recurring UTI’s/ Cystitis / Thrush
Anorexia/Bulimia / C-section in last 6 mos / Candida
Laxative Use / Colonoscopy / Liposuction/Laser Lipo

Women Only

Experiencing PMS / Regular periods / Are you on the pill
Post Menopause / Trying to Conceive / HRT

Lifestyle

Do you sleep well

Do you have a high stress lifestyle
Do you exercise regularly

Medications and Supplements

How often do your bowels open ______

Do you ever take laxatives or extra fibre______

Typical Days Food

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids/water/coffee

Declaration

I understand that Colonic Hydrotherapy is part of an overall approach to diet and lifestyle, and I agree to have this treatment.

Signature …………………………………………… Date ……………………………….

Therapist Signature …………………………………………..

Client name:______

Treatment Information
Date.
Abdomen Sensitivity
Bowel - atonic/spastic/normal
Waste- consist / colour
Mucous - level/ colour
Caecum- normal/heavy/toxic
Water volume/ tanks used
Water temperature
Peristalsis – good/poor/none
Gas - gross/ferm/excessive
Implant used
Comments.
Treatment Information
Date.
Abdomen Sensitivity
Bowel - atonic/spastic/normal
Waste- consist / colour
Mucous - level/ colour
Caecum- normal/heavy/toxic
Water volume/ tanks used
Water temperature
Peristalsis – good/poor/none
Gas - gross/ferm/excessive
Implant used
Comments.
Treatment Information
Date.
Abdomen Sensitivity
Bowel - atonic/spastic/normal
Waste- consist / colour
Mucous - level/ colour
Caecum- normal/heavy/toxic
Water volume/ tanks used
Water temperature
Peristalsis – good/poor/none
Gas - gross/ferm/excessive
Implant used
Comments.

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