Whatsymptomsorhealthconcernbringsyoutothisappointment?
Pleaselistanydisease,illnessorailmentsyouhavebeendiagnosedwith:
Haveyoubeenhospitalized,orhadsurgery,oranyorgan(s)removed?_
ContraindicationsforcolonhydrotherapyandotherdigestivedisorderspleasemarkwithaYorN:
IBSColitisCrohn’sUlcerDiverticulitisDiabetesPolypsGallstones Appendicitis KidneyStones AnalFissure ColonCancer Surgery Hernia RenalFailure Livercirrhosis Hemorrhoids HeartFailure Areyoupregnant? Intestinalperforation_____
Listanymedicationyou arecurrentlytaking(prescriptionandoverthecounter)alongwiththereasonwhyyouaretakingit.
Doyoutakeanyofthefollowingsupplements?Howoften?Probiotic x/day,Magnesium x/day,
Digestiveenzymes x/day,Fiber sp/tbspx/day, Vit.Cx/day,Multivitaminx/day,Protein(grams/day)
Emotions:Whatisyourcurrentlevelofstress?Minimal______Average Considerable
Arethereanystressfulcircumstancesinyourliferightnow? Are you willing to discuss? Howmanyhoursofsleepdoyouget/night? Doyouwakefeelingrested?
Doyouexperience(YorN):MoodSwings?Depression?Anxiety?PMS?
Howoftendoyoueatthefollowingperweek?RedMeatPoultryFishNutsFruit Vegetables(raw) (cooked) Dairy BakedGoods WholeGrains Chocolate FastFood WhiteFlourproducts(rice,bread,pastaetc.) Naturaljuicing Alcohol Coffee Pop Cigarettes Howmanyglassesofwaterdoyoudrinkdaily? Doyoueatbreakfastdaily?
Listanyfoodallergies? Whatfoodsdoyoucrave?
Areyouonacleanseorspecialdiet?Areyouavegetarian/vegan?
Forhowlong?
Doyouexercise?_Weights/cardio?Areyouinterestedinweightloss?
Chemicals(YesorNo)
Wereyouasmoker?Ifyouquit,when?Doyoutakeantibioticsatleastonce/year? Drinktapwater? Eatorganicfruitandvegetables? Haveyoutravelled outside Canada inthelastyear?
Doyouexperiencethefollowingdigestivedifficulties(pleasecheckallthosethatapply):Bloating,Constipation ,Heartburn ,Gas ,Burping ,Diarrhea ,Abdominalpain ,Fatigue ,Headaches ,JointPain_
Doyouuselaxatives? Whatkindandhowoften?Doyouuseantacids?
StoolIndicators(Yes/No)
Thefollowingarehelpfulindicatorsofthehealthofyourbowelsaswellasyouroverallhealth.Undereachheadingpleasecircleallresponsesthatapplyinanaverageweek.Ifyouhavebeenexperiencingdiarrheapleaseindicatethis.
Howmanybowelmovementsperweek(#)?
Doyouhavetopushorstrain?Doyouhavepain?
Doyoutakefibersupplements?Areyourbowelmovementslarge(6-8”)andsolid?
Doyouexperiencefrequentboutsofdiarrhea?Isthereahistoryofcancerinyourfamily?
I,theundersigned,acknowledgethatthepersonnelatAquapureColonicsarenotprescribing(orderingforuseasmedicine)formeatanytime,andIwillnotholdthemaccountableforsuch.AnyrecommendationsIreceivearenotintendedasprimarytherapyforanysymptomordisease,butasameansofenhancingthequalityofmydiet.Iunderstandthat ColonHydrotherapyisaprofessionalservice,whichmayprovideinformationrelatedtonutritionalrequirements;howeverthisserviceisnotatool fortheprevention,assessment,diagnosis,ortreatmentofanyparticularillnessordisease.TheservicesIreceiveareinitiatedatmyownrequestforreasonspersonaltome.IunderstandthatallsessionsandseriesIpurchasearenon-refundablebutcanbetransferredtoafriendatanytime.Iamresponsibletobeatmyscheduledappointmentontime.IfImissorcancelmyappointmentwithoutgiving24hoursnoticebyphoneIagreetobechargeda$50latecancellationfeetoAquapureColonicsorhavetheequivalentdeductedfrommycurrentseriesofcolonicsonfile.
Clientsignature ClientProgressSheet(TherapistUseOnly)