CLIENT HEALTH INFORMATION FORM Name:____________________________________________________________________________Date:_______________________ Address:______________________________________________________________________________________________________ City: __________________State: ________Zip:________________Phone/day:____________________Eve:_____________________ Email _______________________________________________________________________________________________________ Business/Occupation: _____________________________________ If referred , by whom:____________________________________ How did you hear about us:_____________________________________________________________________________ _______ HEALTH INFORMATION Height:__________ Weight: ___________Age; ________ Male:_______ Female:_________ Are you experiencing any of the following conditions: Constipation: Menstrual problems: Bowel Gas: __________ Headaches: _______ Hemorrhoids: ________ ________ _____ Heartbur ________ Bloating _______ Poor ___ Indigestion: __________ Slow Healing: ________ n: : concentration: __ Overweig _______ _________ Candida ____ Cellulite: Aching joints: ________ Allergies/Asthma: ht: _ : _______ _ Do you have? Bruise easily: Diarrhea: _________ Acne: _______ High ________ Water retention: ____ Are you experiencing any of the_following conditions: ________ stress: _ _ Constipation: Menstrual problems: Controlled by meds: ___ Uncontrolled: ___ Controlled by diet: ____ CHF: ___ Bowel Gas: __________ Headaches: _______ Hemorrhoids: ________ ________ _____ High blood pressure: __ indicate___________________________________________________________________________________ Heart problems (please Heartbur ________ Bloating _______ Poor ___ Indigestion: __________ Slow Healing: ________ n: : concentration: __ Health habits: How often do you use any of the following? D -daily O –occasionally R -rarely: Overweig _______ _________ Candida ____ Cellulite: Aching joints: ________ Allergies/Asthma: ht: _ : _______ _ Bruise easily: Cigarettes______ Diarrhea: Alcohol_____ _________ Acne: _______ High ________ Water retention: ____ Laxatives_______ Coffee_____ Sodas____ Antacids_______ Aspirin / Motrin______ ________ _ stress: _ _ by meds: ___ Uncontrolled: ___ Controlled by diet: ____ CHF: ___ Dietary habits: D –daily Controlled O- occasionally R –rarely: High blood pressure: __ How often do you eat: Meat________ Dairy products________ Whole grains_______ Vegetables______ Fruit_________ Refined foods ( white bread, white rice, pasta, cookies)____________Sweets/ desserts_________ Fast food___________ How many glasses of water do you drink daily? Do you take vitamins, herbs or homeopathic medicines? Please specify Do you take any medications? please specify Number of bowel movements each day____________________or week_______________________ Have you been diagnosed with any of following : Irritable bowel disorder (IBS)______Colitis:_______ Crohns Disease:_______ Diverticulitis _______Severe Hemorrhoids______ Fissures_______ Colon Cancer _______ Are you Pregnant? _______ Have you had abdominal surgery within the past year? __________If yes please specify Other major surgeries?__________________________________________________________________________________________ Why did you come to see us today? Thank you Who would NOT be a candidate for colon hydrotherapy treatments? If you have a concern about your health or the appropriateness of colon hydrotherapy you should consult a doctor. If you are diagnosed with diverticulitis, ulcerative colitis, Crohn’s disease, severe hemorrhoids, rectal or intestinal tumors, have undergone recent radiation therapy, have uncontrolled hypertension, congestive heart failure, or organic valve disease, have an aneurysm, blood clots, severe anemia, GI hemorrhage/perforation, cirrhosis of the liver, fissures or fistulas, have an hiatal or abdominal hernia, have had recent colon cancer or colon surgery or renal insufficiency then you would NOT be a candidate for colon hydrotherapy treatments. Pregnant women are also advised to only receive colon hydrotherapy during the second trimester of their pregnancy and under the direct supervision and advice from their physician. Professionally administered colon hydrotherapy is generally safe if you are free of the above cited conditions/contraindications. -DISCLAIMER - Every therapy, service, and product described or presented at Rockwall Colonic and Wellness Center is not a cure for any disease, ailment, or health condition. No medical claims are expressed or implied, either directly or indirectly, regarding the therapies, products, or services presented herein. We do not diagnose, treat, or prescribe. We are not licensed massage therapists so we require permission to touch you, if you desire, for services such as a Foot Detox Spa and possibly foot reflexology and/or an abdominal massage during your colonic. I agree that the above information is accurate to the best of my knowledge. I give Rockwall Colonics and Wellness Center permission to evaluate (not diagnose, treat or prescribe) and provide colon hydrotherapy and other holistic alternative modalities. I am aware of and do not have contraindications. I have received a copy of Rockwall Colonic and Wellness Center Policies, as well as a list of the contraindications for colon hydrotherapy and I hereby agree that I am responsible for my health and the services received here. I am th aware of my 9 Amendment Rights to practice alternative health modalities. Your Signature ___________________________________________ Date __________ Phone Number ____________________________