Client Questionnaire

Please fill in the form below to send required information to the therapist before your treatment.

Please give the following contact details, and tick your preferred method of contact.

Please answer the following as accurately as possible:

Are you seeing your Doctor at present?

Do you suffer from any of the following – please tick:

Have you ever had surgery of colon or rectum?
Have you ever had a bowel biopsy?
Have you a prostate biopsy made through the bowel ?
Have you had abdominal surgery e.g. hysterectomy?
Recent Laparoscopy ?
Are you undergoing chemo-therapy and cancer treatments?
Do you take oral or rectal steroids?
Have you undergone recent (within 6 months) hip/knee joint surgery?
Are you pregnant?
Are you breastfeeding?

Do you smoke?
Do you drink alcohol?
Do you drink water?
Do you have any special diet?

General Bowel Movements

Do you require laxatives?

How would you describe your bowel movements? Please tick where appropriate:

Do you suffer from any of the following? Please tick where appropriate:

Declaration

I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if recommended by my Therapist

Colon Hydrotherapy is a safe and effectively cleanses your large intestine –colon. Your Therapist does not diagnose disease or prescribe medications. Should any of your responses to any of the above questions contraindicate colon hydrotherapy you will be advised to seek your doctor’s help. It is responsibility to provide full and complete answers so your Therapist can treat you correctly. Also you must inform us of any changes to your health between treatments.

General Data Protection Regulations (GDPR)

I consent to the data I have given to be used for the purposes of documenting and communication in regards to the treatment I am undertaking.

 Yes

I understand the data and information on paper copies will be stored securely and any data stored on electronic devices will be password protected.

 Yes

Only information to my treatment will be held and it will be stored for no longer than necessary

 Yes

My data will not be passed to any third party without my consent.

 Yes

I am happy to receive any information on promotions and/or newsletter

I consent to being contacted by