Colon Hydrotherapy Intake Form
Personal Information
_____________________________________________________________________________
Last Name
First Name
Date of Birth (mm/dd/yy)
_____________________________________________________________________________
Mailing Address
City
Province
Postal Code
____________________________________________________________________________
Home Telephone
Cell Phone
E-mail Address
Preferred Method of contact: Home Cell Email
(Circle one)
Sex: M F
Age: ______
How did you hear about The Lakeside Clinic? ________________________________________
Emergency Contact:
Name: ____________________Relationship:________________Phone:___________________
Indicate you main Health Concerns in order of importance to you:
1. _____________________ Since when? ___________________________
2. _____________________ Since when? ___________________________
3. _____________________ Since when? ___________________________
List any Medications or Supplements you are currently taking:
1.
2.
3.
4.
5.
_____________________
_____________________
_____________________
_____________________
_____________________
Are you currently pregnant?
How
How
How
How
How
Long?
Long?
Long?
Long?
Long?
____________________________
___________________________
___________________________
___________________________
___________________________
Y N
Acidophilus:
Are you currently taking Acidophilus? Y N
Which Brand? _____________ Dosage ____
Fibre:
Are you currently taking a Fibre Supplement? Y N
Which Brand?________ Dosage____
Water Consumption:
How much per day? ______________________
Type?_________________________
Bowel Movements:
BM`s per day: ______ Colour _____________ Consistency _______________
Do you experience any of the following?
Straining
YN
Undigested Food
Have you ever had a Colonic before? Y N
YN
Rectal Bleeding Y N
When?__________________
***Please indicate which of the following conditions you have experienced in the past or are
suffering from currently.
P = Past Condition C = Current Condition
Abdominal Pain
P
C
Belching
P
C
Bloating
P
C
Acne/Boils
P
C
Depression
P
C
Overweight
P
C
Allergies/Hives
P
C
Diarrhea
P
C
Parasites
P
C
Asthma
P
C
Diverticulitis
P
C
Polyps
P
C
Bad Breath
P
C
Eczema
P
C
PMS
P
C
Dark Circles under Eyes
P
C
Fatigue
P
C
Psoriasis
P
C
Offensive Body Odour
P
C
Fibromyalgia
P
C
Cancer
P
C
Blood in Stool
P
C
Gallstones
P
C
Rectal Fissures
P
C
Rashes/Skin Issues
P
C
Headaches
P
C
Rectal Itch
P
C
Crohn's Disease/Spastic Colon
P
C
Heartburn
P
C
Rosacea
P
C
Coated Tongue
P
C
Hemorrhoids
P
C
Sinusitis
P
C
Colitis
P
C
IBS
P
C
Ulcers
P
C
Constipation/Gas
P
C
Nausea
P
C
Vomiting
P
C
***Please indicate if you CURRENTLY have any of the following conditions.
Congestive Heart Failure
Y
N
Inguinal Hernias
Y
N
Aneurysm
Y
N
Uncontrolled High BP
Abdominal Surgery (past 2
months
Y
N
Y
N
N
N
Y
N
Rectal Bleeding
Kidney
Insufficiency
Y
Y
Rectal Fistulas
Colon/Rectal
Tumours
Y
N
I, the undersigned, consent to Colon Hydrotherapy treatment through the use of sterile equipment and
warm filtered water. I understand that these procedures are for the purpose of detoxification and the
cleansing of the colon and are not intended to take the place of medical care or medications. I
understand that there is a possibility of minor abdominal discomfort during the treatment. I clearly
confirm that I do not have any of the contraindications to Colon Hydrotherapy (as noted above). I
understand that I can discontinue treatments at any time. I agree to pay my account in full after every
treatment.
Signature: ________________________________ Date: _____________________
Name: (Please Print)____________________________________