BROOKSIDE WELLNESS COLON HYDROTHERAPY INTAKE FORM 504 Shartom Drive Augusta, Georgia
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1 BROOKSIDE WELLNESS COLON HYDROTHERAPY INTAKE FORM 504 Shartom Drive Augusta, Georgia Date First Name: M.I. Last Name: Mobile number: Emergency contact number: How did you hear of us? Height: Weight: D.O.B. Why have you chosen to have this procedure at this time? CONTRAINDICATIONS: HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE BELOW? If any of these conditions have ever occurred, contact us at abdominal hernia acute liver failure Crohn s disease diverticulosis fistula lupus cosmetic surgery anemia (severe) abdominal surgery aneurysm (all types) colitis diverticulitis hemorrhoidectomy currently pregnant tumors abdominal distention weight loss surgery colon carcinoma dialysis intestinal perforations renal insufficiencies prostatitis I HAVE NOT BEEN DIAGNOSED WITH ANY CONTRAINDICATION FOR COLON IRRIGATION (SEE THE LIST ABOVE). I AM AWARE THAT COLON HYGIENISTS ARE NOT MEDICAL DOCTORS AND THEREFORE DO NOT INSERT, DIAGNOSE, OR PRESCRIBE. I AM AWARE ADVERSE EVENTS SUCH AS PERFORATION, INJURY, AND ILLNESS HAVE OCCURRED WITH THE USE OF COLON HYDROTHERAPY AND ENEMA DEVICES. I AM RESPONSIBLE FOR MY OWN SELF-INSERTION. IF I EXPERIENCE RESISTANCE DURING INSERTION OR PAIN, I AM RESPONSIBLE FOR IMMEDIATELY STOPPING MY SESSION AND NOTIFYING THE HYGIENIST. THIS IS NOT MEANT TO BE INCLUSIVE OF ALL POSSIBLE RISKS ASSOCIATED WITH COLON HYDROTHERAPY, AS THERE ARE BOTH KNOWN AND UNKNOWN SIDE EFFECTS ASSOCIATED WITH ANY MEDICATION OR PROCEDURE. Client signature:
2 Please check any of the following you have recently experienced abdominal hernia burning / itching anus hemorrhoids recent colonoscopy bladder infection heart trouble rectal bleeding vomiting blood in stool high blood pressure recent barium enema laxatives How often do you have bowel movements? Several daily Once daily Every 2-3 days Twice weekly Once per week Are your movements at a consistent time of day when you have a movement(s)? Always Sometimes Never Must you use a laxative to have a bowel movement? Never Sometimes Always Must you generally strain to complete a bowel movement? Never Sometimes Cannot pass without straining Have you ever done this type of colon cleansing procedure before? Yes (how long ago) No (it s my first such procedure Circle any other conditions (HIV, AIDS, Hepatitis A, B, or C) Are you currently under the care of a physician? YES NO Have you had any surgical procedure within the past 12 months? YES NO Informed Consent I, the undersigned, am in full agreement that colon cleansing is not a proven method, cure, or treatment of disease or condition, nor has it been portrayed as such. Colon cleansing in this facility is a self-administered procedure where, I as the user of the device, am solely responsible for my own actions and release liability regarding my health issues. The devices being used in this facility are FDA registered Class I gravity devices that can be used prior to endoscopic procedures. The facility I have chosen to visit is aware of the laws governing this facility at the time I sign this waiver of consent and that at anytime those laws can change and neither I, my family, nor my representative(s) responsible for my personal choice to receive colon cleansing at this facility nor hold them liable for any changes or variations of the law after the time of my dated signature below. All results of my sessions are contributive to research and the
3 utilization in future programs of self-health aid, while preserving my privacy, and waive any liability on behalf of the technician serving me. Client signature Date General Health Information (check only if this is an ongoing issue for you) frequent urination acne constipation dry skin itching nausea poor appetite excessive hunger allergies depression jaundice overweight skin eruptions sweats gall bladder trouble belching gas chest pain diarrhea fainting abdominal pain kidney trouble difficult breathing blood in urine chills fever insomnia liver trouble parasites HABITS How many hours of SLEEP do you get nightly (on average) How many days a week do you EXERCISE? How many glasses of WATER do you drink daily? How many serving of fruits do you eat daily? How many servings of whole grains do you eat daily? Do you consume any of the following daily? Alcohol Coffee Tea Soft drinks Do you take any of these on a daily basis? Multivitamins Supplements Herbs Probiotics Digestive Enzymes LIST ANY PRESCRIPTION MEDICATION(S) YOU ARE TAKING AT PRESENT:
4 Please circle any of the following prescription drugs you are taking : Celexa (citalopram) Lexapro (escitalopram) Prozac (fluoxetine) Luvox (fluvoxamine) Paxil (paroxetine) Zoloft (sertraline) Relaphen Feldene Heparin Warfarin Clopidrogel Naproxen (Aleve) Aspirin (Bayer, Bufferin, Excedrin) Ibuprofen (Advil, Motrin IB) Thank you for your business. SEE THE FORM BELOW FOR BEST RESULTS.
5 For Best Results NOTE: If this is your first time doing a colon cleanse, you should prepare by drinking 64 ounces of water the day before and not eating any solid foods 2 hours before the scheduled start time the day of the procedure. WHAT TO EXPECT AFTERWARDS 1. You can eat immediately after your cleanse; however, for the next 4 hours, do not eat, a) red meat, b) white starches, or c) dairy products. 2. Schedule your follow-up cleanse within 14 days of your initial visit to maximize the cleanse. It can be as soon as the second day after your first cleanse. 3. The earliest you will have another well-formed movement will be the following morning; however, most will not have another movement for 2-4 days, if not regular before the initial cleanse. 4. You are able to resume normal activity after your cleanse because with the newer devices we use, we are able to ensure that the water is out of your system, which allows you to continue through the remainder of your day.
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:
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
CLIENT INFORMATION. Last Name: First Name: Address: City, Zip: Date of Birth: / / Primary Number: Home: Cell/Alternate: Work:
CLIENT INFORMATION Today s Date: / / Last Name: First Name: Parent Guardian of Client? Name and Relationship to Client: Address: City, Zip: Email: Date of Birth: / / Primary Number: Home: Cell/Alternate:
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