HEALTH QUESTIONNAIRE (In strictest confidence)
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1 HEALTH QUESTIONNAIRE (In strictest confidence) Please save this document, complete, save and return to us by or post. Alternatively bring the completed form with you to your appointment. If you have any problems please contact Full name (including title).. Address (including postcode). Telephone number (best to reach you on).. address ( address for communication purposes and from time to time, Gedling Colonics send out health tips). 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?.. If yes, what were they prescribed for? Are you, or have you, in the past, taken recreational Drugs? If yes, please give details.... Do you have any children? If yes, how old?..
2 'Do you have any pets - cats, dogs etc?.. Current health complaints and duration..... Are you consulting your GP or a Hospital Specialist regarding your health? If so, what for?... Please list any prescribed medications you are taking.. Do you/have you ever taken any steroid based medication?... If so, what for and what was the duration?..... List all past medical problems with approximate dates.... List all surgical procedures in the last two years. Have you ever been hospitalised, either as a baby, child or adult for an infection that required the prescribing of antibiotics, particularly intra-venous antibiotics? If so, what for, when, and the duration of your stay in hospital? Were you born by caesarean or was it a natural birth? Were you breast fed or bottle fed? 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
3 receiving.. Do you suffer from, or have suffered from: High blood pressure. Heart disease Severe haemorrhoids Hernia... G.I. Haemorrhage? Perforation... Fissures/Fistulas Kidney failure or kidney problems.. Cirrhosis of the liver Cancer of the colon/rectum. Recent colon surgery Severe anaemia. Any bleeding from the rectum. If you have answered Yes to any of the above, please give details.. Have you ever had any of the following procedures?: Colonoscopy. Barium Enema Sigmoidoscopy.. Scans of the Abdominal area. Gastroscopy (sometimes referred to as Endoscopy - camera down the throat)... If you have answered Yes to any of the above, please give details.. Do you, or have you in the past ever administered rectal enemas? Have you had colonic hydrotherapy before? If so, with whom, and when..... Any family health conditions....
4 Has a close family member (parents, grandparents, brother, sister) been diagnosed with bowel cancer, crohn's disease, coeliac disease, colitis, diverticulitis? If so, please give details.... 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? Have you ever smoked? If so, when did you stop... and how many cigarettes were you smoking each 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? Do you suffer from any food allergies/food sensitivities?.. If yes, please list....
5 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 Heartburn 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 Depression Bruise easily Fatigue Dermatitis
6 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 C.O.P.D 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..
7 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. What do you think needs to change to improve your health? List your main reasons for wanting Colon Hydrotherapy... How did you hear about Jane and Gedling Colonics? (recommended/website/google etc.). The information provided above is, to the best of my knowledge, true and accurate. I also confirm that I have not with-held any health/personal information that may affect the therapist's decision to treat me with colon hydrotherapy. Signed.. Date. I agree to having a rectal examination if during discussion it is deemed necessary Signed Date..
8 If suffering from diabetes, angina, heart disease, or epilepsy, in the event of an attack, I agree to the following action being taken: (delete as appropriate): administer my medication/call an ambulance/call relative/position comfortably. Signed... Date...
Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex
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Name (First Name and Last Initial ONLY) Date. Occupation. Education. Date of Birth Age Gender. How did you hear about AHE NYC World Student Clinic?
Name (First Name and Last Initial ONLY) Date Occupation Education Date of Birth Age Gender How did you hear about AHE NYC World Student Clinic? Family History Age If passed, cause of death Father Mother
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synhealthcare.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home Phone: