CLIENT HEALTH INFORMATION FORM
Name:____________________________________________________________________________Date:_______________________
Address:______________________________________________________________________________________________________
City: __________________State: ________Zip:________________Phone/day:____________________Eve:_____________________
Email _______________________________________________________________________________________________________
Business/Occupation: _____________________________________ If referred , by whom:____________________________________
How did you hear about us:_____________________________________________________________________________ _______
HEALTH INFORMATION
Height:__________ Weight: ___________Age; ________ Male:_______ Female:_________
Are you experiencing any of the following conditions:
Constipation:
Menstrual problems:
Bowel Gas: __________ Headaches: _______ Hemorrhoids: ________
________
_____
Heartbur
________
Bloating _______
Poor
___
Indigestion: __________
Slow Healing: ________
n:
:
concentration:
__
Overweig
_______
_________ Candida
____
Cellulite:
Aching joints: ________ Allergies/Asthma:
ht:
_
:
_______
_
Do you have?
Bruise easily:
Diarrhea: _________ Acne:
_______
High
________
Water retention:
____
Are you experiencing any of the_following conditions:
________
stress:
_
_
Constipation:
Menstrual
problems:
Controlled
by
meds:
___
Uncontrolled:
___
Controlled
by
diet:
____
CHF:
___
Bowel Gas: __________ Headaches: _______ Hemorrhoids: ________
________
_____
High
blood
pressure:
__ indicate___________________________________________________________________________________
Heart
problems
(please
Heartbur
________
Bloating _______
Poor
___
Indigestion: __________
Slow Healing: ________
n:
:
concentration:
__
Health
habits:
How often do you use
any of the
following? D -daily O –occasionally R -rarely:
Overweig
_______
_________
Candida
____
Cellulite:
Aching joints: ________ Allergies/Asthma:
ht:
_
:
_______
_
Bruise easily: Cigarettes______
Diarrhea: Alcohol_____
_________ Acne:
_______
High
________
Water
retention:
____
Laxatives_______
Coffee_____
Sodas____
Antacids_______
Aspirin
/ Motrin______
________
_
stress:
_
_
by meds: ___
Uncontrolled: ___
Controlled by diet: ____ CHF: ___
Dietary habits: D –daily Controlled
O- occasionally
R –rarely:
High blood pressure: __
How often do you eat: Meat________ Dairy products________ Whole grains_______ Vegetables______
Fruit_________ Refined foods ( white bread, white rice, pasta, cookies)____________Sweets/ desserts_________ Fast
food___________ How many glasses of water do you drink daily?
Do you take vitamins, herbs or homeopathic medicines? Please specify
Do you take any medications? please specify
Number of bowel movements each day____________________or week_______________________
Have you been diagnosed with any of following :
Irritable bowel disorder (IBS)______Colitis:_______ Crohns Disease:_______ Diverticulitis _______Severe Hemorrhoids______
Fissures_______ Colon Cancer _______ Are you Pregnant? _______ Have you had abdominal surgery within the past year?
__________If yes please specify Other major
surgeries?__________________________________________________________________________________________
Why did you come to see us today?
Thank you
Who would NOT be a candidate for colon hydrotherapy treatments? If you have a
concern about your health or the appropriateness of colon hydrotherapy you should consult a
doctor. If you are diagnosed with diverticulitis, ulcerative colitis, Crohn’s disease, severe
hemorrhoids, rectal or intestinal tumors, have undergone recent radiation therapy, have
uncontrolled hypertension, congestive heart failure, or organic valve disease, have an
aneurysm, blood clots, severe anemia, GI hemorrhage/perforation, cirrhosis of the liver,
fissures or fistulas, have an hiatal or abdominal hernia, have had recent colon cancer or colon
surgery or renal insufficiency then you would NOT be a candidate for colon hydrotherapy
treatments. Pregnant women are also advised to only receive colon hydrotherapy during the
second trimester of their pregnancy and under the direct supervision and advice from their
physician. Professionally administered colon hydrotherapy is generally safe if you are free of
the above cited conditions/contraindications.
-DISCLAIMER - Every therapy, service, and product described or presented at Rockwall
Colonic and Wellness Center is not a cure for any disease, ailment, or health condition. No
medical claims are expressed or implied, either directly or indirectly, regarding the therapies,
products, or services presented herein. We do not diagnose, treat, or prescribe. We are not
licensed massage therapists so we require permission to touch you, if you desire, for services
such as a Foot Detox Spa and possibly foot reflexology and/or an abdominal massage during
your colonic.
I agree that the above information is accurate to the best of my knowledge. I give Rockwall
Colonics and Wellness Center permission to evaluate (not diagnose, treat or prescribe) and
provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do
not have contraindications. I have received a copy of Rockwall Colonic and Wellness
Center Policies, as well as a list of the contraindications for colon hydrotherapy and I
hereby agree that I am responsible for my health and the services received here. I am
th
aware of my 9 Amendment Rights to practice alternative health modalities.
Your Signature ___________________________________________ Date __________
Phone Number ____________________________