Confidential Health Intake Form

for Colonic Hydrotherapy  

Advance Detox Center

7365 carnelian St., Suite 204

Rancho Cucamonga, Ca. 91730

PH: 909-989-1144   

email: info@detoxwithcolonics.com

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.

Your Signature

Disclaimer:

The information on this website is for educational purposes only. It is based on the personal and professional experiences of the author and should not be taken as professional medical advice or used as a substitute for medical care. No statements contained herein have been evaluated by the Food and Drug Administration.

In addition, nothing on this website is intended to diagnose, cure, treat or otherwise mitigate any disease. If you need a medical diagnosis you are encouraged to seek the advice of a qualified medical doctor. We advise that you consult with your physician before making any exercise or dietary changes or taking any nutritional supplements.

© Copyright 2021 Advance Detox Center | All Rights Reserved 

7365 Carnelian Street, Suite 204

Rancho Cucamonga Ca. 91730

909-989-1144

info@detoxwithcolonics.com

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