Colon Hydrotherapy Intake Form

Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­________________________________________________________Today’s Date______________

Address:________________________________________________________________________________

City:_________________________ Province:_______________ Postal Code:_______________________

Phone:_____________________ Email:_______________________________________________________

May we contact you at the above email with upcoming promotions, etc? Y/ N

Date of Birth:__________________________Age:__________ Sex (Please Circle) M F

Height:______________Weight:_____________ Do you have any children?(Circle) Y N

Number of Children:______ Are you pregnant right now? Y/ N

Ever Had A Colonic Before Y/ N When?_________________Where?______________________________

How did you learn of our services?___________________________________________________________

Major Physical Complaints_________________________________________________________________

List All Surgeries & Dates__________________________________________________________________

List all prescription medications you are presently taking_______________________________________­­­­___

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List all vitamins and/or herbal supplements you are presently taking_________________________________

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Do you drink caffeine Y/N How much caffeine daily?_____________

Do you smoke? Y / N (Circle) Cigarettes/Cigar/Other____________________________________________

List all known allergies or sensitivities:________________________________________________________

How many bowel movements do you usually have per day?_________________

Do you take laxatives? Y / N

○ Herbal Laxatives Brand:_________________________________________

○ Suppositories Brand:_________________________________________

○ Stool Softeners Brand:_________________________________________

I have chosen to have colon hydrotherapy because (circle all that apply): Doctor Referral/ 9th Amendment Right to Self Prescribe/ Other (Explain):______________________________________________________

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In case of emergency call_________________________________Phone:____________________________

I understand that all information shared in this visit is confidential and for educational purposes only and that it is not intended to replace your general medical practitioner.

Client Signature: ________________________________________________Date:_____________________

By initialing, I certify I am not presently diagnosed with the following contraindications_____________ (initial here)

Severe Hemorrhoids Abdominal Hernia Fissures Fistulas

Heart Disease Kidney Disease Perforations Cirrhosis

Rectal/Colon Surgery Colon Cancer G.I. Hemorrhage Aneurysm

Renal Insufficiency Severe Anemia Chron’s Disease Ilecolitis

Congestive Heart Disease Hypertension Rectal Cancer, SIBO or other rectal problems.

If you have experienced any of the above contraindications, list which ones and how long ago you experienced them:___________________________________________

______________________________________________________________________________________________________________________________________________________________________________

I understand that I am having Colon Hydrotherapy at my own risk and that Kleen Kolonics its owners, agents, management and employees assume no liability of any kind. I have been truthful in answering all the above statements, and am solely responsible for such.

Disclaimer

A Certified Colon Therapist is not a medical doctor and does not perform any medical diagnosis or treatment procedures. The services provided by a certified colon hydrotherapist are at all times restricted to consultation on the subject of nutritional matters or the sensitivities to various substances. Recommendation for other therapies (if any) are done for informative purposes only and does not involve diagnosing, curing, prognosticating, treatment or prescribing of remedies for the treatment of disease or any act, which will constitute the practice of medicine in this province for which a license is required. All suggestions (if any) regarding herbs or nutritional matters are based on historical and traditional use

Signature:___________________________________________________Date:________________________