Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex
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1 Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex HEALTH QUESTIONNAIRE (In strictest confidence) Full name (including title).. Address (including postcode). Telephone number (best to reach you on).. address. Date of birth.. Age Height. Weight. Occupation.. Name and address of GP. Blood Group (if known)... Have you received any antibiotic treatment in the past six months?.. Do you have any children? If yes, how old?.. Current health complaints..... Please list any prescribed medications you are taking.. List all past medical problems with approximate dates.... List all surgical procedures in the last two years. Are you taking any vitamin/mineral supplements? If so, please list... Are you currently consulting any other practitioners? If so, please give details of the treatment you are
2 receiving.. Do you suffer from, or have suffered from: High blood pressure. Heart disease Severe haemorrhoids Hernia... G.I. Haemorrhage? Perforation... Kidney failure.. Cirrhosis of the liver Cancer of the colon/rectum. Recent colon surgery Severe anaemia. Fissures/Fistulas If you have answered Yes to any of the above, please give details.. Any family health conditions.... How often do you urinate? 3-4 times a day. Less. More. Any back pain? Yes No How often How regular are your bowel movements?.. Is there ever any mucous in your stools? Does stress affect your bowel movements? Do you crave any particular type of food and if so what?.. Do you smoke?.. If yes, how many a day? Do you drink alcohol? If yes, how many units per week?. How many cups of tea and/or coffee do you drink a day?.. Do you add sugar and if so, how much?. Do you drink soft drinks (cola etc.) and if so, how many? How many glasses of water do you drink each day?.. How often do you exercise? How many hours sleep do you need/get?... Do you have a good appetite?
3 Do you suffer from any food allergies/food sensitivities?.. If yes, please list.... Do you frequently travel abroad?... If yes, have you ever suffered with sickness and/or diarrhoea?. Are you under a lot of stress at the moment?.. If yes, do you know the cause of it? Please tick if you suffer, or have suffered from any of the following conditions: General Gastro-intestinal Alcoholism Abdominal pain Amalgam fillings-how many Bad breath Anaemia Colitis Cancer (of any type) Constipation Chronic Fatigue Syndrome Cravings Diabetes Diarrhoea Dizziness Distension/abdominal bloating Double/blurred vision Diverticulitis/Diverticulosis Drug addiction Hearburn Fainting spells Indigestion Ear infections Irritable Bowel Syndrome Epilepsy Liver trouble (e.g. fatty liver) Headaches/Migraines Rectal bleeding Hepatitis Rectal itching HIV/Aids Ulcerative Colitis Hypoglycaemia M.E. Weight loss Over-active thyroid gland Under-active thyroid gland Gallstones Cardio-vascular Muscle and joint Angina/Chest pain Arthritis Hardening of the arteries Low back pain Low blood pressure Joint pain/stiffness Rapid irregular heart beat Rheumatism Swelling of the ankles Muscle weakness Emotional/nervous system Skin Anxiety Acne
4 Depression Bruise easily Fatigue Dermatitis Insomnia Eczema Irritability Fungal infections Lack of concentration Psoriasis Lethargy Mood swings Over-reacting Panic attacks Memory loss Respiratory Women Asthma Amenorrhoea (absence of periods) Bronchitis Dysmenorrhoea (painful periods) Emphysema Endometriosis Hayfever Genital herpes Sinus problems Genital warts Heavy menstrual flow Hysterectomy PMT Vaginal thrush Are you pregnant? Date of last period Are you on the Pill? Genito-urinary Men Bladder infections Enlarged prostate Kidney infections/stones Genital herpes Genital warts Daily diet please give an indication of a typical daily diet Breakfast. Mid-morning Lunch Mid-afternoon.. Dinner.. Have you ever suffered from anorexia or bulimia?. Do you ever over-eat?. Are you vegetarian or vegan or neither? Do you feel that certain foods upset you and if so, which? Please give any other information you may think is relevant.
5 List your main reasons for wanting Colon Hydrotherapy... The information provided above is, to the best of my knowledge, true and accurate Signed.. Date. I agree to having a rectal examination if during discussion it is deemed necessary Signed Date..
HEALTH QUESTIONNAIRE (In strictest confidence)
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