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 Allergies Arthritis Asthma Colitis Constipation Indigestion Diabetes Diverticulitis Cancer Bad Breath High / Low Blood Pressure Fatigue Heart Condition Headaches Candida / Thrush Depression Bleeding from rectum Do you suffer from any other illness/condition? Do you take any Vitamins?YesNo If Yes, which ones: /p> Do you get colds/flu?YesNo If Yes, how often each year?: /p> Do you have any cravings/binges?YesNo Do you have any eating disorders?YesNo Date of last period: /p> Are you pregnant?YesNo Are you taking laxatives?YesNo Are you taking antibiotics?YesNo 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?YesNo Do you eat bread?YesNo How many litres of water do you drink each day: Describe your energy levels : I completely understand that Colonic Hydrotherapy is for cleansing purposes only & does not substitute in any way proper medical or psychological treatment and no guaranteed results can be given. I confirm that all the above information is true and correct. SIGNATURE Date *PLEASE DOUBLE-CHECK ALL INFO IS CORRECT BEFORE SUBMITTING AND CLICK 'SUBMIT' A SECOND TIME TO SEND*
