COLON HYDROTHERAPY INTAKE FORM Colonic Hydrotherapy Intake Form All information will be held in strict confidence. This information may help your therapist to assist you better in your quest for optimal colon hydrotherapy results. It is not intended to diagnose or prescribe and is not a replacement for your regular medical attention by your physician. Name * Date * Address * Contacts (Cell) * Home Email Occupation Date of birth * Have you ever had Colon Hydrotherapy Before? If yes, please state when was the last one Other cleansing Experience includes What is your reason for having Colon cleanse? How did you hear about us? HEALTH CONDITIONS Any problems with: Constipation Diarrhea Abdominal Pain Hemorrhoids Gas How often do you have a bowel movement? Any other colon problems? (Now) Any other colon problems ? (In the Past) Have you taken in the past Antibiotics Chemical Laxatives Birth Control Food allergies or Food restrictions Diagnosed Health conditions Do you have or are you a carrier of an infectious disease? if so what ? Do you presently have or have you had in the last three (3) years any of the following conditions? Cancer of the Colon or GI tract Vascular aneurism History of Seizures Acute abdominal pain Renal insufficiency Carcinoma of the rectum Congestive heart failure Epilepsy or Psychoses Abdominal surgery Uncontrolled Hypertension Cirrhosis Severe hemorrhoids Diverticulitis Intestinal perforation Recent heart attack Recent heart attack General Debilitation Abdominal Hernia Recent colon or rectal surgery Pregnancy If yes briefly explain. Liability Waiver I declare that I am with full legal capacity and physical condition to receive Colon Hydrotherapy treatment and I do it with full knowledge and understanding that if I am not truthful I will be responsible for any risks implicated therein. I hereby acknowledge and agree to receive therapies/treatments from Nirvana Natural Health Clinic with the understanding that the possible risks and/or injuries which I may sustain personally will be my full and complete responsibility. Through this signing I release Nirvana Natural Health Clinic as well as all its employees and associates. Client/Customer * Date * If you are human, leave this field blank. Submit
