_____________________Colon Hydrotherapy Intake Form____________________________
Name: _________________________________________
Date: ______________________
Address: _______________________________________________________________________
City, State, Zip Code: ______________________________________________________________
Email:__________________________________________________________________________
Phone: __________________________________________
Height: ______________________
DOB: _______________________
Weight: _____________________
How did you learn or our services? _____________________________________________________
Are you now under a Doctor’s care, if so please list Physician name and reason for
treatment:________________________________________________________________________
_________________________________________________________________________________
List your major physical complaints:
_________________________________________________________________________________
_________________________________________________________________________________
Do you take any of the following on a regular basis, if so please be specific:
Vitamins: _________________________________________________________________________
Supplements: _____________________________________________________________________
Over the Counter remedies: __________________________________________________________
Prescription Medication: ____________________________________________________________
Recreational Drugs and/or Alcohol:
_________________________________________________________________________________
__________________________________________________________________________________
Do you take acidophilus? If so, what type? :____________________________________________________
Have you ever taken Psyllium? ______________________________________________________________
Do you eat dairy products and if so, how often? ________________________________________________
Do you drink coffee or strong tea? If so, how many cups per day?
_______________________________________________________________________________________
Do you take diuretics? _____________________________________________________________________
Do you exercise, if so, how often? ___________________________________________________________
How often are your bowel movements? ______________________________________________________
_______________________________________________________________________________________
Do you strain to have a bowel movement? ____________________________________________________
Do you take a stool softener or laxative regularly? If so, what type? ________________________________
_______________________________________________________________________________________
Do you have hemorrhoids? If so, do they irritate you? ___________________________________________
_______________________________________________________________________________________
Do you have rectal bleeding? If yes, when, why and how often? ___________________________________
_______________________________________________________________________________________
Have you ever had rectal surgery? If so when and what purpose? _________________________________
_______________________________________________________________________________________
Typical Diet: ____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________________________________
Candida Questionnaire
Disclaimer: Please note this questionnaire is not a complete diagnosis in and of itself, neither is it
intended to diagnose any type of illness.
Are your health problems yeast connected?
Answer the following questions to determine if your health issues have a yeast connection.
Answering yes to more than 5 questions, means candida possibly plays a role, answering yes to
over 8 questions, increases the probability. The higher you score the more likely it could be a
chronic candida overgrowth.
Please mark what best applies:
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Fatigue or Lethargy
Feeling of being drained of energy
Feeling mental fog or poor concentration
Depression, moodiness or changeable moods
Headaches
Cravings for sweets, bread or alcohol
Numbness, burning or tingling anywhere
Muscle aches or weakness
Painful joints or swelling in joints
Abdominal pain and digestive problems
Constipation or diarrhea
Bloating or indigestion
Troublesome vaginal discharge
Persistent vaginal burning or itching
“Jock itch” or prostatitis
History of athlete’s foot, ringworm or other chronic fungus infections
Impotence or history of infertility
Lack of sexual desire
Menstrual irregularity or cramps/pain during menstruation
PMS
Spots in front of eyes
Poor erratic vision
Antibiotic usage within the past two years
Feeling of “bad all over” but the cause hasn’t been found
Cancellation Policy
We kindly ask for the courtesy of a 24-hour notification of cancellation in the event you are
unable to show for your appointment, if we do not receive the timely notice, please understand
that a non-waivable fee of $50 will be charged to your account. If you have purchased any
packages, please understand that failure to give proper 24 –Hour notification, will result in the
forfeit of that session. If you voluntarily choose to terminate your Colon Hydrotherapy midsession, please be aware that there will not be any refunds for the service.
Transfers of sessions may only be done if you are transferring the service to an Existing Colon
Hydrotherapy patient at our facility, for a $10 fee.
By signing below you agree to have read and abide by the policy stated above.
Name: _____________________________________________________
Signature: ____________________________________________
Date: _________________
Parent/Guardian (if Minor):_______________________________________________________
DC Employee Signature: __________________________________________________________
The Business and Professions code of the State of California
-Section 2053.6
***All patients must read, understand and sign this disclosure***
Colon Hydrotherapy services provided at this office comply with Section 2053.6 to the Business and Professions Code of the
State of California. In Compliance with this Code, you must avoid:
A. Though there are Licensed Medical Professionals at this office, the individual performing the colon hydrotherapy
is ONLY a Certified Colon Hydrotherapy. This means and implies that they will not:
1.
B.
Conduct Surgery or any other procedure on another person that punctures the skin or harmfully invades
the body.
2. Administer or prescribe X-Ray radiation to another person.
3. Prescribe or administer Prescription drugs or controlled substances to another person.
4. Recommend the discontinuance of prescription drugs or controlled substances prescribed by
appropriately.
5. Wilfully diagnose and treat a physical or mental condition of any person under any circumstances or
conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death.
6. Set Fractures
7. Treat lacerations or abrasions through electrotherapy
8. Hold out, state, indicate, advertise, or imply to a patient or prospective patient that he/she is a physician
and surgeon.
Colon Hydrotherapy is alternative or complimentary to healing arts services licensed by the state.
C.
The Services of Colon Hydrotherapy and the Therapist that provide the services are NOT licensed by the state.
D. The Session of colon Hydrotherapy includes the following procedure:
1.
2.
3.
4.
E.
The therapist will insert and retract the speculum.
Warm (Temperature and Pressure controlled) water will flow into the colon, softening the fecal
material, which will be released by normal peristalsis into the sewer.
Your dignity and modesty will be maintained at all times.
The session will last approximately 30-45 minutes.
The theory of treatment upon which colon hydrotherapy is more historical and intuitive than scientific as there
have not been any studies to validate the effectiveness of this modality. However, many cultures and societies
believe that a clean colon can enhance the health of the individual. This started thousands of years ago with
the simple enema and has evolved into the present day colonic. Many people simply report they feel better
after a colonic. On the other hand, there are a growing number of healthcare practitioners that believe in the
concept of auto-intoxication, that a sluggish bowel (one that is not regular) allows the body to re-absorb toxins
of the colon. This theory may or may not have validity depending on who you listen to, but we know there is an
increased level of toxins in our environment and common sense tells us that anything we can do to assist the
body in ridding itself of toxins should have some value.
I acknowledge that I have read the above disclosure and have received a copy of this document. This
information was provided to me in a language I can read and understand.
_____________________________________
_____________________
Patient Signature
Date