Client Health Questionnaire

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Frank Chandler
6 years ago
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Client Health Questionnaire Contact Information Name: Date: Address: City and Zip: Phone: (cell) (hm) (wk) Email Address: Date of Birth: Height: Weight: Sex: Male Female Marital Status: Married

1 Client Health Questionnaire Contact Information Name: Date: Address: City and Zip: Phone: (cell) (hm) (wk) Address: Date of Birth: Height: Weight: Sex: Male Female Marital Status: Married Single Other # of Children: Ages: Occupation: Hobbies & Activities: Emergency Contact Information: Relationship: Phone 1: Phone 2: Physician: Phone: Are you currently under a doctor s care? Yes No (If YES, explain below) Date of last complete Physical Exam: Results: Is your Physician aware you are receiving colon hydro-therapy? Yes No *Have you ever had colon hydrotherapy? Yes No (If YES, explain where and when below) - 1 -

2 ***How did you learn of our services? Please state your reasons for and expectations from receiving colon hydrotherapy: FOR WOMEN ONLY Yes No Yes No Are you pregnant? Is there a chance you might be pregnant? Are your periods regular? Do you suffer from PMS? Do you take birth control pills? Do you take Hormone supplements? Date of last Colonoscopy: FOR MEN ONLY Yes No Yes No Do you have difficulties urinating? Do you take Hormone supplements? Date of last Colonoscopy: Please explain all yes answers below: DAILY HABITS What do you typically consume for: Breakfast: Lunch: Dinner: Snack: Daily Water Consumption: Beverages: Alcohol: What and How often: Rec.Drugs: - 2 -

3 Do you exercise? Yes No Describe: Please describe your dietary intake: (example; vegan, vegetarian, food combining, non-vegetarian- beef, pork, poultry, seafood, home cooking, home/dinning out, fast food, etc.) Please circle the foods you have consumed in the last 2 Weeks: BEEF CHEESE PIZZA WHITE BREAD MUSTARD PORK CREAM CHEESE ICE CREAM WAFFLES NUTRI SWEET LAMB SOUR CREAM PIE POPCORN MSG CHICKEN COTTAGE CHEESE CANDY CEREAL EQUAL FISH WHIPPING CREAM COOKIES FRENCH TOAST RANCH TURKEY MIRACLE WHIP DONUTS ENGLISH MUFFIN MAYO CAKE BAGELS CATSUP EGGS KEFIR PASTRIES FRENCH FRIES BUTTER YOGURT PANCAKES CHIPS MILK PRETZELS SOY SAUCE SALT On a scale from 1 to 5, (with one being low and five being very high) what best describes your usual stress level? (please circle) Are circumstances in your life increasing your usual stress level? (share if you wish) Are you interested in learning more about diet and lifestyle changes? y n - 3 -

4 Eating Behaviors Circle any behaviors you have, or have experienced: OVEREATING BINGE EATING ANOREXIA BULIMIA EATING WHEN FATIGUED EATING WHEN IN PAIN EMOTIONAL EATING LATE NITE EATING Do you feel food addicted? Y N Do you eat slowly and chew well? Y N Are you able to eat and drink what you intuitively feel is right for you? Y N Other conditions {indications for Colon Hydrotherapy} Circle any of these challenges you have/do experience: BACKACHES FOOTACHES CANDIDASIS BAD BREATH ALLERGIES ECZEMA SKIN DISORDERS BODY ODORS IRREGULAR PERIODS HEADACHES CHRONIC FATIGUE ATHSMA ARTHRITIS DIABETES COLD FEET/HANDS FEVER CHEMICAL SENSITIVITY JOINT MUCSLE PAIN INSOMNIA Emotional/Mental States Circle any you experience(d): DEPRESSION IRRITABLE RESTLESS ANGER/HURT SAD CODEPENDENT GRIEF FORGETFUL ANXIOUS FEARFUL ABUSED BI-POLAR OBSESSIVE/COMPULSIVE UNHAPPY DESPAIR - 4 -

5 Possible Contraindications: Have you ever been treated for any of the following conditions? (check all that apply) Rectal Bleeding Cancer Appendicitis Abdominal Surgery Low Blood Pressure IBS Crohn s Disease Ulcerative Colitis Severe Anemia Renal Insufficiency High Blood Pressure Colitis Fissures/Fistulas Abdominal Hernia AIDS Cardiac Disease Cirrhosis HIV Cancer Aneurysm Hepatitis (What Type) Congestive Heart Failure Please explain all checked conditions: VITAL HEALTH INFORMATION In order to provide the best possible care and to insure optimum results from you colon hydrotherapy session, the following information is essential. Please complete this section thoroughly and completely. All information contained herein, is strictly confidential. (Please list all and for what purpose) Prescription Medications: Supplements: Over the Counter Medications: List all known allergies: List the type and year of all surgeries and major illnesses: - 5 -

6 Have you ever had? (If yes, when) Colonoscopy Sigmoidoscopy Endoscopy Rectal Surgery Bowel Habits How often do you have a bowel movement? Yes No Occasionally Do you suffer from constipation? How Long? Do other members in your family suffer from constipation? (Parents, siblings etc.) Yes No Do you suffer from diarrhea? Do you suffer from hemorrhoids? (circle all that apply) Internal/ External / Both Mild / Moderate / Sever Have you ever had hemorrhoids surgically corrected? When? Do you take laxatives? What type? How often? Do you strain to make a bowel movement? Do you take diuretics? What type? How often? Do you take fiber? What type? How often? Do you take stool softeners? What type? How often? Have you ever taken psyllium? When? - 6 -

7 Who would NOT be a candidate for colon hydrotherapy treatments? If you have a concern about your health or the appropriateness of colon hydrotherapy you should consult a doctor. If you are diagnosed with diverticulitis, ulcerative colitis, Crohn s disease, severe hemorrhoids, rectal or intestinal tumors, have undergone recent radiation therapy, have uncontrolled hypertension, congestive heart failure, or organic valve disease, have an aneurysm, blood clots, severe anemia, GI hemorrhage/perforation, cirrhosis of the liver, fissures or fistulas, have an abdominal hernia, have had recent colon cancer or colon surgery or renal insufficiency then you would NOT be a candidate for colon hydrotherapy treatments. Pregnant women are also advised to only receive colon hydrotherapy during the second trimester of their pregnancy and under the direct supervision and advice from their physician. Professionally administered colon hydrotherapy is generally safe if you are free of the above cited conditions/contraindications. Colon Hydrotherapy is a process, not a quick cure. Multiple sessions combined with good eating habits and regular exercise can be necessary to achieve optimum results. It is advised before beginning diet, exercise, or a complimentary modality, to discuss it with your physician. Colon hydrotherapy is not intended to replace the relationship with your primary health care providers and my consultation is not intended as medical advice. They are intended as a sharing of knowledge and information from my education, research, experience and community. As a colon hydrotherapist, I encourage you to be as open to new information on the effectiveness of colon hydrotherapy and the foundational role of diet, exercise, supplementation, stress management and emotional and mental work. I encourage you to make your own health care decision based upon your research and in partnership with your primary heath care providers. The information and service provide is not use to prescribe recommended diagnose or treat a health problem or a disease. It is not a substitute for medical care. If you have or suspect you may have a health problem, you should consult your primary health care providers. I agree that the above information is accurate to the best of my knowledge. I give Northshore Colonics LLC, permission to evaluate (not diagnose, treat or prescribe) and provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do not have contraindications. I have received read Northshore Colonics LLC Policies, as well as a list of the contraindications for colon hydrotherapy and I hereby agree that I am responsible for my health and the services received here. I am aware of my 9 th Amendment Rights to practice alternative health modalities. *Policies: 24 hour Notice for any cancellation is required. If we are not notified YOU will be charged $ We honor and respect your time and hope you understand that we are here to help and cannot help someone else if you do not notify us changes to your schedule- Thank you I agree and understand the information presented to me. I read above information I have disclosed herein to be true and accurate. (Print Name) (Signature) (Date) - 7 -

8 NORTHSHORE COLONICS, LLC 1535 Lake Cook Rd Suite 113 Northbrook, Il INFORMED CONSENT FORM I,, have been informed and fully understand that Colon Hydrotherapy has been presented to me as a hygienic method of cleansing the colon. Colon Hydrotherapy has not been presented to me as treatment or cure for any illness or specific disease or with any guarantee to heal any disease. Whether or not I participate in this program is my decision, which I have chosen as a positive action for my personal preventive health care. Furthermore, I understand that failure to give 24 hour notice for a missed appointment will result in my account/credit card will be charged $ for the missed Colon Therapy session. *Colon Hydrotherapy is not intended to replace the relationship with your primary health care providers and my consultation is not intended as medical advice. It is intended as a sharing of knowledge and information from my education, research, experience and community. As a Colon Hydrotherapist, I encourage you to be open to new information on the effectiveness of colon hydrotherapy and the foundational role of diet, exercise, supplementation, stress management and emotional and mental work. I encourage you to make your own health care decisions based upon your own research and in partnership with your primary health care providers. The information and service provided is not used to prescribe, recommend, diagnose or treat a health problem or a disease. It is not a substitute for medical care. If you have or suspect you may have a health problem, you should consult your primary health care providers I agree that the above information is accurate to the best of my knowledge. I give Northshore Colonics,LLC permission to evaluate (not diagnose, treat or prescribe) and provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do not have contraindications. I have received and read Northshore Colonics Policies, as well as a list of the contraindications for colon hydrotherapy and I hereby agree that I am responsible for my own health and the services received here. I am aware of my 9 th Amendment Rights to practice alternative health modalities. I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS: DATE: PRINTED NAME: SIGNATURE:

COLON HYDROTHERAPY CONSENT FORM

Last Name: First Name: FOR OFFICE USE COLON HYDROTHERAPY CONSENT FORM Client No: Origination date: Note: Client Name: Date: / / Preferred Phone: Text: Y / N Email: Email: Y / N Address: State: Zip Code: