The Village Wellness Center
1404 Starling Dr.
Richmond, VA 23239
804-673-2936
Colon Hydrotherapy Client Intake Form
Today’s Date:
Client Name:
Date of Birth:
Street Address:
City:
State:
Home Phone:
Cell Phone:
Work Phone:
Zip:
Extension:
E-mail Address:
How did you hear about us?
Male
Female
Occupation:
Have you ever had a Colon Hydrotherapy?
If so, how many times?
How long since your last colonic?
How many bowel movements do you usually have per day?
How would you describe your bowel movements?
Please check which apply: With Ease
Sticky
Formed
Straining
Undigested Food
Discomfort
Bloating
Gas
Dry
Cramps
Please describe the type and frequency of your discomfort as well as any activity that aggravates
the condition. (Example: dull, sharp, off and on, when standing, sitting, driving, etc.)
When did you become aware of this problem?
What caused it?
Is the condition getting worse?
Y
N
What are you currently doing to get relief?
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The Village Wellness Center
1404 Starling Dr.
Richmond, VA 23239
804-673-2936
Have you ever had a barium enema?
Y
N
When:
Have you ever had a sigmoidoscopy?
Y
N
When:
Have you ever had a colonoscopy?
Y
N
When:
If female, are you pregnant?
Y
N
If so, which trimester?
Have you had, or currently have, diverticulitis, ulcerative colitis, crohn’s disease, or carcinoma
of the colon? Y
N
If so when:
Do you have any heart, liver, or kidney problems? Y
Do you have high blood pressure?
Y
N
Do you have any fissures or fistulas?
Y
N
Have you ever had an aneurysm?
Y
N
N
If so, please explain:
Have you ever experienced a gastro-intestinal hemorrhage or perforation? Y
If so when?
Do you currently have, or have had, a hernia?
Y
N
Do you have hemorrhoids or other rectal issues?
Y
N
Are you anemic?
If so when?
Y
N
Have you been anemic in the past?
Have you experienced bleeding from your rectum? Y
N
Have you experienced bleeding from any other body orifices?
If so, when?
Y
If so, when?
Y
N
Please list any surgeries and their dates:
Do you use stool softener or laxative?
Y
N
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If so, what kind?
N
N
The Village Wellness Center
1404 Starling Dr.
Richmond, VA 23239
804-673-2936
Please list any medications you are currently taking:
Please list any herbal/nutritional supplements you are currently taking:
Are you allergic to anything? Y
N
If so, what?
I, the undersigned, authorize Holli Greenspan to administer Colon Hydrotherapy sessions. Holli
Greenspan is not a physician and therefore is not qualified to diagnose or prescribe. I understand
how Colon Hydrotherapy is performed and used, and I acknowledge the potential benefits and
risks of Colon Hydrotherapy.
In order to provide care and services to our other clients, we ask that you give 24 HOURS
NOTICE WHEN CANCELLING or rescheduling appointments. When less notice or missed
appointment occurs, you will be charged a $25 fee.
Client signature:
Date:
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