Confidential Health Intake Form

for Colonic Hydrotherapy  

Advance Detox Center

7365 carnelian St., Suite 204

Rancho Cucamonga, Ca. 91730

PH: 909-989-1144   


Are you curently under a Doctor's care?
Are you currently taking any medications?
Do you have any Contagious Diseases?
Do you have any allergies?
Have you had any surgeries?
Female Clients: Are you currently pregnant? (If yes, we regret that we are unable to provide treatments during pregnancy.)
How is your general health?
Are you currently taking any supplements?
Are you seeing any other practitioners or therapits for treatments?
Have you ever had a Colonic before?
Please select: My Bowel movements are:
How regular are your bowel movments?
Do you suffer from any of the following? (mark all that apply)
Do you have mucus in your stools?
Does stress affect your bowel movements?
Please mark if you have had any of the following procedures:
Have you taken antibiotics in the past?
Is there family history of intestinal problems?
Have you have any of the following conditions?
Do you use any of the following?
THE FOLLOWING ARE CONTRAINDICATIONS FOR COLON HYDROTHERAPY - If any of these apply to you we are not able to treat you with Colon Hydrotherapy at the present time.

Thanks for submitting!