Colon Hydrotherapy Questionnaire
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- Earl Fisher
- 6 years ago
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1 Colon Hydrotherapy Questionnaire Full Name: Address: Telephone: Occupation: How did you hear about us? Date of Birth: Please list any conditions for which you are currently being treated: Women Only: Are you pregnant? Y/N Are you trying to conceive? Yes/ NO Do you have children? Y/N How Many? How Old? Medications: Drug Name Dosage Condition Being Treated Duration Supplements & Herbs: Names Dosage Condition Being Treated Duration
2 What are your main health concerns? (Please tick/ circle all that apply to you) General Alcoholism Allergies Anaemia Cancer Diabetes Dizziness/ Fainting Spells Ear problems Anorexia/ Bulimia Epilepsy Eye Problems Gout Headaches Migraines Hepatitis Hernia HIV / AIDS Hypoglycaemia Kidney Problems Liver Problems ME MS STI/ STD's Thyroid Problems Weight Problems Visual Floaters Emotional/Nervous System Anxiety or Stress Depression Fatigue Hyperactive Insomnia / Sleep Problems Irritability Lack of Concentration Lethargy Mood Swings Panic Attacks Poor Memory Eye Tics Pins & Needles Gastrointestinal Abdominal Pain Bad Breath Bloating Bloody / Black Stool Candida Colitis Constipation If so for how long? Colon / Rectum Cancer Diarrhoea Diverticulosis Food Cravings Gastrointestinal Infections / Bugs Haemorrhoids Heartburn / Reflux IBS Indigestion Jaundice Mucus In Stools Rectal / Anal Bleeding Rectal / Anal Itching Ulcers Cardiovascular Angina/ Heart Problems Blue/ Cold Extremities Chest Pains Low/ High Blood Pressure Palpitations Poor Circulation Swelling Of Ankles/ Legs Varicose Veins Women Acne Breast Problems Caesarean Section Endometriosis/ Fibroids Poly Cystic Ovarian Syndrome Excessive Hair Growth Genital Herpes Genital Warts Hair Loss Having Difficulty Conceiving Hysterectomy Low Sex Drive Contraception Type: Miscarriage Painful / Heavy Periods Age of 1st Period Regular Periods Termination Thrush / Cystitis Water / Fluid Retention
3 Skin Athletes Foot Bruise Easily Dermatitis Eczema Irritations Itching / Rashes Psoriasis Verrucas / Warts Muscles & Joints Arthritis Back Pain Joint Pain/Stiffness Muscle Cramping Restless Legs Investigations & Operations: Respiratory Asthma Breathlessness Bronchitis Constant Runny Nose Hay Fever / Rhinitis Persistent Cough/ Phlegm Sinus Problems/ Infections TB Smoking Immune System Allergies / Intolerances Coated Tongue Cold Sores Frequent Mouth Ulcers Reg Infections Nail Infections Regular Antibiotics Regular Colds/ Flu Traveller s Bugs Other Problems: Men Acne Enlarged Prostate Excessive Sweating Frequency of Urine Urination Overnight General Herpes Genital Warts Infertility X-Ray/ Scans: Barium Meal: Colonoscopy: Endoscopy: Biopsies: Surgeries: Please list all recurring illnesses/diseases that occur within the family: Grandparents: Parents: Siblings:
4 What are your current bowel habits? Frequency (per day/week) Present Consistency (skinny/ pellets/ loose) *Gas *Bloating *Mucous *Bleeding Are you currently taking or have you used laxatives in the past? Y/N Types What would you like to achieve from this treatment? Diet: (Please list a typical day) Breakfast: Snacks: Lunch: Snacks: Dinner: Snacks: Please list quantity of fluids per day & state if caffeinated or de-caff: Tea: Coffee: Water: Proteins Shakes: Others: Please list any foods you crave: Please list units of alcohol consumed per week: (1 unit=1 small glass of wine, half pint of beer, small spirit) Do you wake up fresh in the morning? Do you need Tea/ Coffee/ Sugar to wake up in the mornings? Do you need Tea/ Coffee/ Sugar at regular intervals? Do you get Dizzy/ Irritable without regular food? Do you get tired particularly after lunch? Do you have poor Memory/ Concentration?
5 Declaration 1. I confirm that all information included in this questionnaire is correct to the best of my knowledge and I have informed the practitioner of all health issues and have not knowingly withheld any information. 2. I understand that colon hydrotherapy is part of an overall approach to diet and lifestyle. 3. I agree to have a digital examination, this ensures that there are no obstructions or lesions which may prevent the insertion of the speculum. Signed: I have read and do not have any of the following contraindications that would prevent me from having this treatment: Cancer, Colon/Rectal Surgery, Inflammatory Bowel Disease/ Colitis, Diverticulitis, Severe Haemorrhoids, Gastrointestinal Bleeding, Abdominal Hernia, Enlarged Prostate, Fissures or Fistula, Pregnancy, Cardiac Disease/ Unstable or High Blood Pressure, Renal Insufficiency, Liver Disease, Insulin Dependant/Unstable Diabetes, Severe Gallstones, Antibiotics. Signed: Date: Therapist: Lisa Manley General Nurse & Colon Hydrotherapist
6 TREATMENT 1. Rectum/ Anus: Water Volume: Implant: Date: Peristalsis: Water Temp: Tx Description: Mucous: Fermentation: Old Faeces : Patient Response: After Care/ Supplementation: TREATMENT 2. Date: Client Feedback: Rectum/ Anus: Water Volume: Peristalsis: Water Temp: Implant: Tx Description: Mucous: Fermentation: Old Faeces: Patient Response: After Care Advice/ Supplementation:
Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex
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Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
Section A: History. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer?
CANDIDA QUESTIONNAIRE DR WENDY WELLS, NMD The total score will help you and your physician decide if your health problems are yeast-connected. ** Yeast-connected health problems are almost certainly present
New Client Health & Wellness Paper Work
Nutritionally Yours Health Solutions 604 Macy Drive, Roswell GA 30076 678-372-2913 / alanepnd@gmail.com New Client Health & Wellness Paper Work Today's Date Patient Name: _ Parents Name (if patient is
PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:
PATIENT INFORMATION Date Name Address First Middle Last City State Zip Home # Cell # Check this box to authorize text messaging for confirming and reminders Email Check this box to authorize our office
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician