Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Home Phone
(###)
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Work Phone
(###)
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How did you hear about From Scratch Wellness colon hydrotherapy services?
Today's Date
MM
DD
YYYY
Birthdate
MM
DD
YYYY
Current Age
Sex
Height
Weight
Do you have any children? If so, how many?
Are you pregnant right now?
Have you ever had a colonic before? If so, where, when, and what type of colonic did you have?
Have you tried other forms of detoxification? If so, please explain...
Major physical complaints:
List all surgeries and dates below:
List all prescription medication you are presently taking:
List all vitamins or herbal supplements you are currently taking:
If you drink caffeine, how much do you consume each day?
If you smoke cigarettes or cigars, how many do you smoke each day?
List all known allergies or sensitivities below:
How many bowel movements do you typically have each day?
If you take laxatives, stool softeners, or suppositories, please list the brands below:
I have chosen to have colon hydrotherapy because:
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
(###)
###
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I certify I am not presently diagnosed with the following contraindications:
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Severe Hemorrhoids,
Abdominal Hernia,
Fissures,
Fistulas Heart Disease, Kidney Disease, Perforations,
Rectal/Colon Surgery, Spinal Injuries, Colon Cancer, G.I. Hemorrhage, other rectal problems.
If you have experienced any of the above contraindications, list which ones and how long ago you experienced them:
I understand that I am having Colon Hydrotherapy at my own risk and that From Scratch Wellness, its owners, agents, management and employees assume no liability of any kind. I have been truthful answering all the above statements, and am solely responsible for such. Scheduling an appointment reserves the equipment time specifically for you. As only one person can use the equipment at a time, kindly give 24 hours notice if you need to reschedule or cancel an appointment. There is a $30 charge for missed or forgotten appointments or if you cancel within 24 hours and we are unable to fill the appointment.
