Confidential Health Questionnaire

All information you give us either in person or on these forms will remain confidential.

Name:___________________________________________________________

Address: ____________________________________________________________

City: _____________________ State: ___________Zip Code:___________________

Phone: (Home) _____________________ (Work or Cell) _______________________

Email address_________________________________________________________

Date of Birth:____________Age:________Sex:______Height:______Weight:______

Occupation: __________________________________________________________

Referred by: __________________________________________________________

Have you ever had a Colon Hydrotherapy treatment before? ____________________

Do you currently:

Smoke (how often or when did you quit): ___________________________________

Drink alcohol (how much and how often): ___________________________________

Drink coffee, tea, or other caffeinated beverage (how much/day): ________________

Drink soft drinks (how much/day):_________________________________________

Exercise (what type, how often): __________________________________________

How much water do you drink each day? ________________________________

List your main health concerns and state briefly how long each has been going on:

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List briefly what you expect from your Colon Hydrotherapy session(s):

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List all medications and/or supplements that you are currently using (please include why you are taking them). Be sure to include non-prescription medications such as aspirin, laxatives, vitamins, minerals, homeopathic, herbs, etc.

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List any surgeries you have had with type and date:

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List any allergies:

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Are you currently under medical treatment for any specific health issue? If so, list the health issue and the treatment you are undergoing:

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List any previous health issues with which you have been diagnosed, but for which you are no longer being treated. Include previous treatment administered:

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Other issues (serious childhood diseases, accidents or injuries, etc.):
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NORMAL BOWEL HABITS: please circle

Do you find any of the following in your stool (bowel movement):  Blood    Mucus

Do you ever have to:  Strain   Take Laxatives

Have you ever consulted your Doctor due to bowel problems? Yes  No

Do you have bowel movements:  Daily __2/3 times a day__every 2-3 days__ Weekly__

________________________________________________________________________  DISCLAIMER

The nutritional and health information given to you by our therapist during any appointment or consultation, whether on the phone or in the office, newsletters or handouts is based on the therapist’s personal experience and research and clients’ results and experiences.  It is intended to help you make informed decisions regarding the state of your health and how your lifestyle choices affect your health. Because there is always risk of unforeseen results when changing your diet and lifestyle, please do not apply this information unless you are willing to assume that risk. If you choose to use diet and lifestyle changes as a form of treatment for any illness or disease without the approval of a medical physician, you are, in effect, prescribing this for yourself, which is your right. If you are ever in doubt about the appropriateness of a treatment for yourself, please consult a physician prior to receiving Nutrition Counseling or Colon Hydrotherapy.

ACKNOWLEDGEEMENT

To the best of my knowledge, all of the preceding answers are true and correct.If any changes in my health or medications occur, I promptly will inform Advance Detox Center. I accept the terms of the foregoing disclaimer and acknowledge that any information I receive from Advance Detox Center is to be used for educational purposes only in order to assist me in making the best decisions concerning my own health. I acknowledge that neither Advance Detox Center claim to be Medical Doctors and will not prescribe for or diagnose any disease or condition. I acknowledge that I am responsible for any decisions I make concerning my health and will not hold Advance Detox Center liable for my decisions or the results of those decisions or of any treatments I receive.

Client Name :______________________________________________( please print)

Client Signature: ____________________________________Date:______________

Advance Detox Center and its therapists have been thoroughly trained and are certified by The International Association for Colon Hydrotherapy.

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Please circle the issues that apply to your current or previous health situation and/or to your family history (parents, grandparents, siblings) marking yours with your initials.

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Indications for Colon Hydrotherapy

Colon Hydrotherapy has been shown to be beneficial for the following: 

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 Contraindications

The following is a list of contraindications for Colon Hydrotherapy. If you have ever been diagnosed with ANY of these conditions Colon Hydrotherapy should not be administered at this time unless you have a Doctors prescription.

I have read and understand the above indications and contraindications for colon hydrotherapy and I agree that I have never been diagnosed with any of the above mentioned contraindications or that I have a doctor’s prescription for Colon Hydrotherapy. I acknowledge that it is my decision to receive colon hydrotherapy and that neither Advance Detox Center nor any of its therapists represent themselves to be Medical Doctors.

Client Name: _______________________________________________(please print)

Client Signature: _____________________________________ Date: ____________