Consultation - Colonic Hydrotherapy "*" indicates required fields Step 1 of 6 16% PERSONAL INFORMATIONFull NameDate of BirthGenderAddress Street Address City/ Town State Postcode Email address* Phone numberHow did you hear about us? Word of mouth/ referral Signage Social Media Online Other Emergency Contact - NameEmergency Contact - Phone numberOccupationWhat do you hope to get out of doing colonics?Reason for consultation? What are your main health concerns?Have you had colon hydrotherapy before? Yes No Unsure If yes, when was your last session? MEDICAL HISTORYAre you currently undergoing any medical treatment with a doctor? Yes No If yes, please specify the reason:Have you been diagnosed with any medical conditions? Yes No If yes, please list:List any current medications:Are you taking?: Steroid medication - Cortisol, Prednisolone, Hydrocortisone Blood thinners/ Anti-coagulants - Warfarin (Coumadin), Plavix, Dabigatran (Pradaxa), Heparin, Rivaroxaban (Xarelto), Dexamethasone, Apixaban (Elquis) NSAIDS (Long-term) - Ibuprofen, Advil, Naproxen Methotrexate Diuretics - Lozol (Indapamide), Chlothalitone (Thalitone), Lasix (Furosemide), Hydrochlorothazide (Hydrodiurill) Hypertensive Drugs - Carvedilol, Linsinopril List any current supplements:Do you use laxatives? Yes No Sometimes Do you have any infectious diseases? HIV Hepatitis Other If other, please specify:Do you have a history of any of the following? Heart Disease Kidney Disease Liver Disease Colorectal Disorders Diabetes High Blood Pressure Anaemia Thyroid Disorder Other If other, please specify:Do you suffer from depression? Yes No Not currently Do you suffer from anxiety? Yes No Not currently Do you have any allergies? Yes No Not currently If yes, please specify:Surgical HistoryHave you has any abdominal or intestinal surgery? Appendectomy (Appendix Removal) Cholecystectomy (Gallbladder Removal) Polypectomy (Polyp removal) Caesarean Colectomy (Colon/ Bowel Resection) Hernia Repair Bariatric Surgery Hysterectomy Other If other, please specify:Have you had any other surgical procedures? Yes No If yes, please specify and when? DIGESTIVE HEALTHHow frequent are your bowel movements? Once per day Twice per day More than twice per day Every other day Once per week Inconsistent Describe your typical bowel movements (frequency, consistency, etc)Please describe as per the Bristol Stool Chart on the right.Do you experience any of the following symptoms? Constipation Diarrhoea Bloating Gas Abdominal Pain Blood in Stool Blood on Toilet Paper Painful or difficult bowel movements Other If other, please specify:DIETARY HABITSDescribe your typical daily diet? Select all that apply: Red meat Fish Poultry Vegetables Fruit Vegetarian Vegan Fast food I eat everything Lactose free Gluten free Other If other, describe your typical daily diet:Do you have any food allergies or intolerances? Yes No If yes, please list:How much water do you drink daily? 1 glass Up to 1 litre 1-2 litres More than 2 litres None LIFESTYLE & GENERAL HEALTH INFORMATIONSelect your level of physical activity: Extremely active Moderately active Not that active Do you smoke or vape? Yes No If yes, please describe frequency and amount:Do you consume alcohol? Yes No Do you consume recreational drugs? Yes No If yes, please describe frequency and amount:If yes, please describe frequency and amount:Do you experience any of the following?: Headaches/ Migraines Low Iron/ Anaemia Menstrual Problems Hearing Problems Visual Problems Depression/ Anxiety Low Blood Pressure High Blood Pressure Vertigo Arthritis Asthma Urinary Tract Infections Candida Circulation Problems Haemorrhoids Heartburn Heart Problems Other If other, please specify: Contraindications for Colon Hydrotherapy A contraindication is any indication or symptom that makes it inadvisable to use a particular therapy. The following are contraindications for colon hydrotherapy. If any of these apply to you, you may not be eligible for colon hydrotherapy sessions at the present time. If you have any of these contraindications, you may still be eligible to receive colon hydrotherapy once they have subsided or been eliminated. Select all that apply to you: Anal Fissure/ Fistula (a tear in the colon) Abdominal Surgery Severe Anemia Cirrhosis Colon Cancer Severe Anxiety Chron's Disease (in the acute inflammatory or bleeding stages) Tumour in the rectum or large intestine Cardiac Disease (Severe, Uncontrolled Hypertension or Congestive Heart Failure) GI Haemorrhage/ Perforation Haemorrhoids (severe or bleeding) Rectal Bleeding (except for minor haemorrhoids) Colon Surgery Ulcerative Colitis Colostomy Hernia (Abdominal/ inguinal) Kidney Dialysis Pregnancy Lupus Renal insufficiency Diverticulitis/ Diverticulosis Endometriosis Rectal Prolapse Other (Anything else that you believe may be contraindicated or affect your treatment If other, please specify: As a Colon Hydrotherapist, I encourage you to be open to new information on the effectiveness of Colon Hydrotherapy and the fundamental role of diet, exercise, supplementation, stress management and emotional and mental work. I encourage you to make your own health care decisions based upon your research and in partnership with your primary health care providers, ND, MD or otherwise. Cancellation Policy*Cancellations or changes to scheduled appointments must be made at least 24 Hours in Advance of the scheduled appointment. Otherwise, you will be billed for the cost of service as a cancellation charge. I agree to the cancellation policy.Packages*Packages are not refundable, not transferable and are valid for 6 months from the purchase date. I agree to the packages policy.Disclaimer*Colon Hydrotherapy is not intended to replace the relationship with your primary health care providers and my consultation as a Colon Hydrotherapist is not intended as medical advice. It is intended as a sharing of knowledge and information from my education, research, training and experience. The information and service provided is not used to prescribe, recommend, diagnose or treat a health problem or disease. It is not a substitute for medical care. I have provided all known medical information. I have completed this consent form to the best of my knowledge and understand that failure to make full disclosure may place me at undue medical risk. I waive and release to the fullest extent permitted by law of all claims, actions, suits against any person from Natural Rhythm Colonics from all liability whatsoever. I am aware that wet areas may be slippery and that I will take care in those areas not to slip and fall. I acknowledge that I am personally liable and do not hold anyone else liable for any consequences that may occur should I slip or fall from not following instructions or for any problems caused by my failure to disclose any relevant health or medical conditions. I have not been diagnosed with any contraindications for colon hydrotherapy. I agree to never have a treatment under the influence of recreational drugs or alcohol. I agree to never have a treatment if I am feeling, weak, unwell, or not physically strong enough to exercise. I understand that I am responsible for my own self insertion. If I experience resistance during the insertion, I will immediately stop my session. I understand that I am responsible for my session. I will be shown how to turn the machine on and off. If I experience discomfort or pain during the session, I am responsible for immediately stopping my session. I am aware that Colon Hydrotherapists are not Physicians and therefore do not insert, diagnose or prescribe. I am aware that Natural Rhythm Colonics does not claim to cure or treat any condition or disease. Natural Rhythm Colonics and its therapists have given me the full opportunity to ask any questions about the procedure and all of my questions if I have any have been answered to my total satisfaction. After such consultation, I have agreed to have the procedure. I agree to the disclaimer.
