Colonic Hydrotherapy Consultation Form

Gather a new client's health history and lifestyle habits before a colonic hydrotherapy session to check for contraindications and plan safe treatment.

Use this template

Name

Nombre

Apellido

Birth Date

Gender

E-Mail

Phone Number

Occupation (if applicable)

How did you hear about 4 Balance and Health?

Name of Referrer (If Applicable)

Nombre

Apellido

Work Status

Do you have children?

Yes No

Marital Status

Single Married Divorced Widowed

Have you had a colonic before?

Yes No

If yes, was it:

Do you have a bowel movement?

Yes No

Does it require straining?

Yes No

Does it feel unfinished?

Yes No

Is it spontaneous and effortless?

Yes No

Describe the amount and appearance.

Tick the statements that apply to your eating habits and lifesytle:

I eat processed foods regularly I drink adequate water I eat fruits and vegetables daily I consume caffeine regularly I have irregular meal times I exercise regularly

Reasons for the treatment (Please tick all that apply):

Detoxification Constipation Bloating Weight Management General Wellness Skin Health

Have these conditions lasted for:

Less Than a Month 1-6 Months 6-12 Months Over a Year

Please check if you had any of the following:

Please check whether you have any of the following conditions for which this treatment is contraindicated:

Pregnancy Crohn's Disease Ulcerative Colitis Recent Surgery Severe Hemorrhoids Kidney Disease

Cigarette Intake:

None Occasional Moderate Heavy

Alcohol Intake:

None Occasional Moderate Heavy

General Stress Level:

Low Moderate High Very High

What therapies do you use regularly?

Blood Pressure: (for practitioner only)

Please add any information on operations/surgeries in the last 5 years

Medications and nutritional supplements used on a daily basis;

Time

Breakfast:

Time

Lunch:

Time

Dinner:

Snacks:

I certify that the information provided above is true and accurate to the best of my knowledge.

Signature

Sign here

Date

Colonic Hydrotherapy Consultation Form

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