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Medical Form - Colon Hydrotherapy New clients

New Client Forms

Medical Form - Colon Hydrotherapy *

All clients to complete before appointment

Name *

First

Last

Mobile Phone *

Date Of Birth *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical History Reasons for the treatment (tick the ones that apply to you *

Kick-start healthy living
Lack of energy
Irregular bowel movements
Constipation
Help with weight loss
Skin problems
Food cravings
Parasites
Detox
Allergies
Bloated
Yeasts/Candida
Increase energy
Headaches/migraines
Diarrhoea
IBS
Gas/Wind

How long has your condition lasted *

Over a Year
2 Years or more
5 Years or longer

Do you have any existing medical conditions? If yes, please state, if none, write none) : *

Are you taking any Antibiotics? If yes, please state, if no please write no *

Have you had Colonic Hydrotherapy before? (If yes, please state when your last treatment was and was it with me) If no, write no: *

Any operations or surgeries in the last 5years? *

Yes
No

If yes please give details as to when? (if none, write none) *

I am not currently undergoing or waiting to start any medical investigations, tests, scans or waiting for results. please Tick *

Tick

Occupation *

Typically what would you eat for Breakfast, Lunch, Tea and Snacks with time eaten *

How much water do you drink per day, not including tea/coffee *

How many hot drinks a day *

Other drinks a day? cordial, juice, fizzy drinks etc *

Do you take laxatives? (if so, please write which ones and how often etc) *

Describe your typical bowel movements, frequency, amount and appearance *

List any surgical procedures you have had in the last 5 years *

List any allergies you may have *

Please check whether you have any of the following conditions for which this treatment is contraindicated: * *

Unmonitored High BP
Ulcerative Colitis
Gl haemorrhage / perf
Covid - 19 / Coronavirus in the past 6 months
Pregnant
Renal Insufficiency
Colorectal Carcinoma
Crohns
Gastric band or Sleeve fitted in last 6 months
Diverticulitis
Tachycardia
None of the above apply

Please check if you have had any of the following: *

Cancer
Diabetes
High Blood Pressure
Bloating
Heart Disease
Headaches
Thyroid Disease
Hepatitis
Rheumatic Fever
Seizures
Thrush
Other
None of the above apply

Please list any Medications and Nutritional Supplements you take and please state mg if applicable and how often etc: *

Have you ever had surgery of colon or rectum? *

yes
no

If yes, when, details etc: (if no, write no) *

Have you ever had a bowel biopsy? *

yes
no

If yes, when, details etc: (if no, write no) *

Have you a prostate biopsy made through the bowel? *

yes
no

If yes, when, details etc: (if no, write no) *

Have you had abdominal surgery e.g. hysterectomy *

yes
no

If yes, when, details etc: (if no, write no) *

Recent Laparoscopy *

yes
no

If yes, when, details etc: (if no, write no) *

Are you undergoing chemotherapy and cancer treatments? *

yes
no

Do you take oral or rectal steroids? *

yes
no

Have you undergone recent (within 6 months) hip/knee joint surgery? *

yes
no

Are you pregnant? *

yes
no

Are you breastfeeding? *

yes
no

Are you undergoing any medical tests or waiting for any results? *

yes
no

Male: Do you have any prostate problems?: *

yes
no

If yes, when, details etc: (if no, write no) *

Have you taken any antibiotics in the last 3 months? *

yes
no

Have you ever fainted or felt faint on the toilet? *

yes
no

Have you been diagnosed with IBS (Irritable Bowel Syndrome)? If yes, give details of date diagnosed, what type etc. If no, write no: * *

Please provide next of kin detail in case of emergency: Name, relation to you and telephone number *

Book an appointment!

Call me at: 07361 237 564 or book online clicking the link below

Book Appointment

Any recommendations on this site are purchased and taken at your own risk. Jade Brown accepts no responsibility for any issues arising from any recommended product on this site.

You should always contact your GP if you have any questions prior to taking any supplements and supplements are never to be taken as an alternative to a healthy and balanced diet and lifestyle.

Please. note: Colonic Hydrotherapy is not in any way intended as a ‘cure’ or ‘medical’ treatment. It should not be seen as an alternative to seeing your GP if you have any health concerns. Neither is intended to infer or imply symptoms of IBS or other bowel conditions will be solved.