Lifestyle Health & Wellness Center

 

COLON HYDROTHERAPY INFORMATION FORM- CONFIDENTAIL

_______________________________________________________________________________________________

Please PRINT and Answer all Questions

NAME_______________________________________         

Home #__________________                Work #___________________

ADDRESS: ______________________________     City:_________________               

State: __________     Zip: _________

OCCUPATION: ____________________________________________________       How Long _________________

HEIGHT: ________   WEIGHT: ________    BIRTH DATE: _______   AGE: ______

Please check*   

Are you Under a Physicians Care? _____________Name: __________________

In Pain __________________                 Where? __________________________________________________

      How did you hear about us?      Physician Referral______Friend______Family ______ Paper__________

Coupon from where? __________________   Internet________  

Colonic Net_________ OTHER? _______________

___Bladder Infection    ___Bloating               ___Blood In Stool        ___BM Painful/Difficult                                     ___Burning/Itching Anus                                ___Diarrhea                                                       ___Infectious Disease  ___Hemorrhoids  Internal___ External ___       ___Rectal Bleeding      ___Recent Barium Enema    ___Recent Colonoscopy___Allergic to Latex   ___Use Laxatives         ___Vomiting       ___Date of Last Menstrual  Other_____

*Contraindication’s: Please check and Date if ever had any of the following:

DATE                                                 DATE        

_____ Abdominal Hernia            ______ Diverticulosis / Diverticulitis

______Abdominal Surgery           ______ Fissures & Fistulas         

______Abdominal Distention        ______ Hemorrhaging                 

______Acute Liver Failure            ______ Hemorrhoidectomy                      

______Anemia                            ______ Intestinal Perforations                 

______Aneurysm, - All Types       ______ Lupus                                                  

______Carcinoma of the Colon     ______ Pregnant – (due date______) 

______Cardiac Condition               _____ Rectal / Colon Surgery                 

______Crohns Disease                 ______ Renal Insufficiencies                     

______ Colitis                              ______ Taking medications?                        

______Dialysis Patients                 List Below or on back

If any checked Please Explain:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _

 I have not been diagnosed with any contraindications for colon irrigation. (See above*)

I am aware that this colon irrigation and enema device facility has a licensed Medical Director that is not on site.

I am aware adverse events such as perforation; injury and illness have been alleged and claimed with the use of colon irrigation and enema devices. Should I experience resistance during the nozzle insertion, I will immediately stop my session. If during the session I experience discomfort or pain, I am responsible for immediately stopping my session.

I am aware that Certified Therapist do not insert, diagnose, prescribe and do not cure or treat any condition or disease. (See back of form for a more complete list of possible side effects.)

CLIENT SIGNATURE _____________________________________________________DATE________________________       

I HAVE REVIEWED THIS FORM WITH MY CLIENT. THERAPIST SIGNATURE______________________________________

STAPLE PHYSICAN PRESCRIPTION HERE

OTHER NOTES/LIST MEDICATIONS: _____________________________________________________________________ __________________________________________________________________________________________________

FIRST SESSION EVALUATION:     YES/NO Did Therapist review Health History and inquire to any health issues?                   ____ Were Device, Room, Restrooms Clean? ____ Were you Covered and Comfortable?   ____ Any Problems or Discomfort?                ____ Please Explain: _______________________ Were your results Satisfactory?               ____ Will you recommend to family/friends? ____ How do you feel? ________________________________________________________________________________________________________________________________________________ Client Signature: ______________________