COLONIC HYDROTHERAPY HEALTH QUESTIONNAIRE
CONFIDENTIAL

    Name

    Date

    Address

    Occupation

    Date of Birth

    How did you hear about us?

    Phone


    Your primary contact number

    Your email

    Referral name

    Health History

    Do you suffer from any other illness/condition?

    Do you take any Vitamins?

    If Yes, which ones:
    /p>

    Do you get colds/flu?

    If Yes, how often each year?:
    /p>

    Do you have any cravings/binges?

    Do you have any eating disorders?

    Date of last period:
    /p>

    Are you pregnant?

    Are you taking laxatives?

    Are you taking antibiotics?

    Lifestyle/diet

    How many units of alcholol do you drink each week:

    What do you normally eat for breakfast? :

    How much caffeine do you drink per week?

    How many times do you eat meat per week?

    Do you consume dairy?

    Do you eat bread?

    How many litres of water do you drink each day:

    Describe your energy levels :

    SIGNATURE

    Date

    *PLEASE DOUBLE-CHECK ALL INFO IS CORRECT BEFORE SUBMITTING AND CLICK 'SUBMIT' A SECOND TIME TO SEND*