Client Intake Questionnaire
Please complete this questionnaire (either typed or by hand), print it out if
possible double sided to save paper, and bring it with you to your first colon
hydrotherapy session with WLC.
Colon hydrotherapy (or colonics) is an adjunct holistic approach to health, not a
medical procedure. The purpose of this questionnaire is to aid in the
consultation that forms part of the first session, and determine your objectives in
having colonics.
Client general details
Name:..........................................................................DOB:................................
Address:.........................................................................................................................
Phone: ...........................................
Email: ..................................................
GP (name / address):
...........................................................................................................
Reason for having colonic: .................................................................................................
............................................................
How did you find out about WLC? .............................................................
Have you had colonics before? If so with whom, how many times; open or closed
system .............................................................................................................
Medical details
Current conditions:.............................................................................................................
Past conditions:...................................................................................................................
Hospital stays / surgery (within last 6 months) .....................................................................
................................................................................................................................................
Current Medication:.............................................................................................................
Supplements: ..................................................... Laxatives ................................................
Episodes of depression / anxiety? Yes / No ......................................................................
Female clients: Are you pregnant? Yes / No (.......... months)
Taking OCP? Yes / No
No of children: .......... Kind of birth(s): ................................
Last period .......................
Painful periods? Yes / No ................................
Menopausal? Yes / No (date ..................)
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Male clients: Prostate issues? ............................................................................................
______________________________________________________________
General Information- (please give details)
Do you exercise regularly? Yes / No ..................................................................................
How do you sleep? ..............................................................................................................
What work do you do? ........................................................................................................
Please describe your average daily diet:
Breakfast: .............................................................................................................................
Lunch: ...................................................................................................................................
Dinner: ..................................................................................................................................
Snacks: .................................................................................................................................
How much of the following do you have per day / week:
Raw Foods: ...........................................................................................................................
Water ..................................... Tea .................................... Coffee .....................................
Other fluids / juices ...........................................................
Alcohol .................................. Smoking ..................................
General Health
Do you have any problems with any of the following: Joints ..................................
Spine ............................................
Skin/nail..............................................
Vision ........................................
Tongue / teeth .......................................... Headaches ................................................
Mucous ............................................... Weight ......................................Height ..................
Is weight management an issue for you? ..................................
Heart ....................................
Blood Pressure .............................................
Blood / Circulation ....................................... Lungs ............................................................
Liver ............................................................... Kidney / Bladder ............................................
Allergies ........................................................ Thrush / Candida ..........................................
Father’s illnesses are / were: ...............................................................................................
Mother’s illnesses are / were: ..............................................................................................
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Bowel details
Bowel regularity ................................................... Stool colour .........................................
Stool consistency ................................................ Stool form (number) ...........................
Constipation ......................................................... Diarrhea ...............................................
Haemorrhoids ....................................................... Bloating ...............................................
Please use this space to share any other information that you think may be
relevant
..................................................................................................................................
List of contraindicated conditions
Abdominal hernia
rectal bleeding
Aneurysm
rectal fissures
Blood clots
renal insufficiency
Cirrhosis of the liver
severe anaemia
Congestive cardiac failure
severe cardiac disease
Colon, kidney or liver cancer
severe haemorrhoids
Crohn's disease
severe prostate problems
Diverticulitis (inflamed, medicated, symptomatic)
Ulcerative colitis
Pregnancy (First trimester)
Uncontrolled high blood pressure
Recent colon or rectal surgery
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If you have been diagnosed with any of the above colon hydrotherapy may not be
suitable for you.
Context for treatment
Colon hydrotherapy is not intended to replace the relationship with your
primary health care providers. Julia Rhodes, our professionally certified colon
hydro therapist is not medically qualified, although she is a (non) practising
physiotherapist. Knowledge, information, insights shared is from education,
research, and experience in the field of holistic health, not the field of medicine.
Neither the information shared, nor the service provided seeks to prescribe,
recommend, diagnose or treat disease conditions. If you have (or suspect you
may have) a health problem needing medical attention, please consult with your
doctor (s).
Consent declaration
If suffering from diabetes, angina, heart disease or epilepsy, in the event of an
attack, I agree to the following action being taken: (delete as necessary)
administer my medication/ call ambulance / call relative/ discontinue treatment
/position comfortably. I confirm I have seen the list of contraindicated
conditions and confirm the absence of any active or current contra-indicated
conditions.
I agree to a rectal examination (in the event this is deemed necessary by the
therapist) and to a colon hydrotherapy treatment as described by the therapist. I
confirm that this form has been completed based on true and accurate
information I have provided.
Client signature ......................................................................... Date .................................
Therapist signature ................................................................... Date ...........................
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