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Colonics Services - Clarity Essential Wellness
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Switzerland
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Taiwan
Tajikistan
Tanzania
Thailand
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Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
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Ukraine
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US Virgin Islands
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Western Sahara
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Other
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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Date of Birth
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Date
Year
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Day
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Phone Number
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Mobile phone number preferred please.
Area Code
Phone Number
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5
E-mail
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6
What is your Profession?
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7
Have you had Colonics Services before?
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YES
NO
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If YES, How long ago?
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9
Any other therapies that you use regularly? For e.g Water/coffee enemas
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10
Are there any supplements/medications you are currently taking.
YES
NO
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11
If yes, please provide further information on names and amounts used.
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12
What is the reason that you are choosing to have a Colonic?
Please select all that apply.
Detox
Increase in energy
Help with weight loss
Irregular bowel movements
Constipation
IBS/ bloating
Diarrhoea
Food cravings
Mood swings
Parasites
Yeast/Candida
Brain fog
Clearer skin
Headaches
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13
Anything not listed previously as a reason above please provide and add further details
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14
Do you have, or have you ever had any of the following conditions which are contraindications?
Please select all that apply.
Severe cardiac disease
High blood pressure not controlled by a doctor
Aneurysm
GI haemorrhage or perforation
Severe haemorrhoids
Cirrhosis of the liver
Carcinoma of the colon
Active fistulas and fissures
Pregnancy
Abdominal hernia
Recent colorectal surgery
Renal insufficiency
Diverticulitis
Ulcerative colitis
Chron’s disease
None of the above
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15
Do you have or have you experienced...
Please select all that apply.
Headaches
Rheumatic fever
Seizures
Thrush
Hepatitis
Bloating
Diarrhoea
Constipation
Fissures
Flatulence
Haemorrhoids
Parasites
Irritable bowel syndrome
Indigestion
Rectal bleeding
Cancer
Diabetes
None of the above
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16
Do you have or have you experienced, dysfunctions/diseases of the following...
Please select all that apply.
Liver
Kidney
Urinary tract
Prostate
Gallbladder
Pancreas
Hormones
Lungs
None of the above
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17
Describe any surgeries and dates
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18
Are you trying to conceive?
Please give as much information as possible.. For eg Naturally, IVF etc and how long have you been trying for?
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19
Are you pregnant? How far?
Details also on any previous pregnancies and dates.
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20
Do you or have you ever...
If you responded with NO, please skip the following question.
Smoke
Drink
Used Drugs/Substances
None of the above
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21
Please provide further details if the previous question applies.
Eg; Start date, finish date, amount per week etc.
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22
Have you had or have an eating disorder?
YES
NO
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23
Do you skip any meals?
YES
NO
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24
Do you eat in a hurry?
YES
NO
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25
Anything we've missed that is important for us to know?
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26
Are you vegetarian/vegan?
YES
NO
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27
Do you eat fruit and vegetables?
If YES, How many servings of each?
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28
Do you have any intolerances to food?
YES
NO
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29
Is there any food you avoid?
If so, why?
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30
What is your fluid intake like? What do you drink on a daily basis and how much?
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What is your food intake like? How much do you eat and how often do you eat daily?
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32
Tell us about your sleeping cycle.
How many hours per night?
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33
How many days per week do you exercise? How long is each session? What type of physical activity?
Eg: 3 days per week, 30 mins, Walking, Jogging, Pilates.
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34
How is the condition of your skin?
Please select all that apply.
Dry
Oily
Normal
Combination
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35
How are the condition of your nails?
Please select all that apply.
Strong
Brittle
Weak
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36
How is the condition of your hair?
Please select all that apply.
Dry
Healthy
Oily
Weak
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37
In the workplace, are you often...
Please select only ONE that applies.
Active
Sedentary
50/50
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38
Wellbeing - Are you/have you experienced/experiencing any of the following?
Please select all that apply.
Levels of Stress
Depression
Fears
Anxiety
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39
If the previous question applies to you, how do you try to combat this/these issue/s?
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40
Are there any aspects of your life that make you unhappy?
If YES, please briefly explain.
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41
If you are female, describe your Menstrual Cycle.
Frequency/Regularity, Pain, Light, Normal, Heavy Flow etc.
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42
If you are female, are you experiencing Menopause? Is it finished, or in process?
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43
If you are female, are you currently using any medications for menstrual cycle/menopause?
If YES, please list name of medication, amount required to take and frequency.
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44
Bowel movements - Do you strain?
YES
NO
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45
Bowel movements - Does the stool float or sink?
Float
Sink
Float
Sink
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46
Bowel movements - Is stool soft or hard?
Soft
Hard
Soft
Hard
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47
Bowel movements - Do you have a lot of gas?
YES
NO
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48
Bowel movements - Is the smell strong?
YES
NO
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49
Bowel movements - Do you notice skid marks in the toilet?
YES
NO
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50
Bowel movements - Describe daily typical bowel movements and frequency.
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51
Bowel movements - Is there anything else we need to know?
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52
Have we missed anything?
Please provide as much information as possible
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53
How did you hear about us?
Facebook
Instagram
Brochure
Google
Website
Referral
Facebook
Instagram
Brochure
Google
Website
Referral
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54
Were you Recommended to us? If so, by who?
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55
Consent Form.
*
This field is required.
We require you to acknowledge this form and tick all boxes below before treatment.
I confirm I have provided to the best of my knowledge all relevant information needed
I consent to have Colon Hydrotherapy at Clarity Essential Wellness
I accept the terms and conditions of my treatment at Clarity Essential Wellness
I agree to notify Clarity Essential Wellness if any changes to my health/medical conditions or lifestyle occur that are different to answers in this document.
I agree to the cancelation policy (and restate it)
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56
Client acknowledgement of Consent Form - Signed By
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Please Print Name.
First Name
Last Name
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57
Date of Signature
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Please select today's date.
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Year
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Day
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