_____________________Colon Hydrotherapy Intake Form____________________________ Name: _________________________________________ Date: ______________________ Address: _______________________________________________________________________ City, State, Zip Code: ______________________________________________________________ Email:__________________________________________________________________________ Phone: __________________________________________ Height: ______________________ DOB: _______________________ Weight: _____________________ How did you learn or our services? _____________________________________________________ Are you now under a Doctor’s care, if so please list Physician name and reason for treatment:________________________________________________________________________ _________________________________________________________________________________ List your major physical complaints: _________________________________________________________________________________ _________________________________________________________________________________ Do you take any of the following on a regular basis, if so please be specific: Vitamins: _________________________________________________________________________ Supplements: _____________________________________________________________________ Over the Counter remedies: __________________________________________________________ Prescription Medication: ____________________________________________________________ Recreational Drugs and/or Alcohol: _________________________________________________________________________________ __________________________________________________________________________________ Do you take acidophilus? If so, what type? :____________________________________________________ Have you ever taken Psyllium? ______________________________________________________________ Do you eat dairy products and if so, how often? ________________________________________________ Do you drink coffee or strong tea? If so, how many cups per day? _______________________________________________________________________________________ Do you take diuretics? _____________________________________________________________________ Do you exercise, if so, how often? ___________________________________________________________ How often are your bowel movements? ______________________________________________________ _______________________________________________________________________________________ Do you strain to have a bowel movement? ____________________________________________________ Do you take a stool softener or laxative regularly? If so, what type? ________________________________ _______________________________________________________________________________________ Do you have hemorrhoids? If so, do they irritate you? ___________________________________________ _______________________________________________________________________________________ Do you have rectal bleeding? If yes, when, why and how often? ___________________________________ _______________________________________________________________________________________ Have you ever had rectal surgery? If so when and what purpose? _________________________________ _______________________________________________________________________________________ Typical Diet: ____________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________ Candida Questionnaire Disclaimer: Please note this questionnaire is not a complete diagnosis in and of itself, neither is it intended to diagnose any type of illness. Are your health problems yeast connected? Answer the following questions to determine if your health issues have a yeast connection. Answering yes to more than 5 questions, means candida possibly plays a role, answering yes to over 8 questions, increases the probability. The higher you score the more likely it could be a chronic candida overgrowth. Please mark what best applies: Fatigue or Lethargy Feeling of being drained of energy Feeling mental fog or poor concentration Depression, moodiness or changeable moods Headaches Cravings for sweets, bread or alcohol Numbness, burning or tingling anywhere Muscle aches or weakness Painful joints or swelling in joints Abdominal pain and digestive problems Constipation or diarrhea Bloating or indigestion Troublesome vaginal discharge Persistent vaginal burning or itching “Jock itch” or prostatitis History of athlete’s foot, ringworm or other chronic fungus infections Impotence or history of infertility Lack of sexual desire Menstrual irregularity or cramps/pain during menstruation PMS Spots in front of eyes Poor erratic vision Antibiotic usage within the past two years Feeling of “bad all over” but the cause hasn’t been found Cancellation Policy We kindly ask for the courtesy of a 24-hour notification of cancellation in the event you are unable to show for your appointment, if we do not receive the timely notice, please understand that a non-waivable fee of $50 will be charged to your account. If you have purchased any packages, please understand that failure to give proper 24 –Hour notification, will result in the forfeit of that session. If you voluntarily choose to terminate your Colon Hydrotherapy midsession, please be aware that there will not be any refunds for the service. Transfers of sessions may only be done if you are transferring the service to an Existing Colon Hydrotherapy patient at our facility, for a $10 fee. By signing below you agree to have read and abide by the policy stated above. Name: _____________________________________________________ Signature: ____________________________________________ Date: _________________ Parent/Guardian (if Minor):_______________________________________________________ DC Employee Signature: __________________________________________________________ The Business and Professions code of the State of California -Section 2053.6 ***All patients must read, understand and sign this disclosure*** Colon Hydrotherapy services provided at this office comply with Section 2053.6 to the Business and Professions Code of the State of California. In Compliance with this Code, you must avoid: A. Though there are Licensed Medical Professionals at this office, the individual performing the colon hydrotherapy is ONLY a Certified Colon Hydrotherapy. This means and implies that they will not: 1. B. Conduct Surgery or any other procedure on another person that punctures the skin or harmfully invades the body. 2. Administer or prescribe X-Ray radiation to another person. 3. Prescribe or administer Prescription drugs or controlled substances to another person. 4. Recommend the discontinuance of prescription drugs or controlled substances prescribed by appropriately. 5. Wilfully diagnose and treat a physical or mental condition of any person under any circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death. 6. Set Fractures 7. Treat lacerations or abrasions through electrotherapy 8. Hold out, state, indicate, advertise, or imply to a patient or prospective patient that he/she is a physician and surgeon. Colon Hydrotherapy is alternative or complimentary to healing arts services licensed by the state. C. The Services of Colon Hydrotherapy and the Therapist that provide the services are NOT licensed by the state. D. The Session of colon Hydrotherapy includes the following procedure: 1. 2. 3. 4. E. The therapist will insert and retract the speculum. Warm (Temperature and Pressure controlled) water will flow into the colon, softening the fecal material, which will be released by normal peristalsis into the sewer. Your dignity and modesty will be maintained at all times. The session will last approximately 30-45 minutes. The theory of treatment upon which colon hydrotherapy is more historical and intuitive than scientific as there have not been any studies to validate the effectiveness of this modality. However, many cultures and societies believe that a clean colon can enhance the health of the individual. This started thousands of years ago with the simple enema and has evolved into the present day colonic. Many people simply report they feel better after a colonic. On the other hand, there are a growing number of healthcare practitioners that believe in the concept of auto-intoxication, that a sluggish bowel (one that is not regular) allows the body to re-absorb toxins of the colon. This theory may or may not have validity depending on who you listen to, but we know there is an increased level of toxins in our environment and common sense tells us that anything we can do to assist the body in ridding itself of toxins should have some value. I acknowledge that I have read the above disclosure and have received a copy of this document. This information was provided to me in a language I can read and understand. _____________________________________ _____________________ Patient Signature Date