4balanceandhealth

Name

TitleFirst NameLast Name

Birth Date

DayMonthYear

Gender

E-Mail

Confirmation Emailexample@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Occupation (if applicable):

How did you hear about 4 Balance and Health?

Name of Referrer (If Applicable):

First NameLast Name

Work Status:

Do you have children?

Marital Status:

Have you had a colonic before?

If yes, was it:

Do you have a bowel movement?

Does it require straining?

Does it feel unfinished?

Is it spontaneous and effortless?

Describe the amount and appearance.

Tick the statements that apply to your eating habits and lifesytle:

Reasons for the treatment (Please tick all that apply):

Have these conditions lasted for:

Please check if you had any of the following:

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

Cigarette Intake:

Alcohol Intake:

General Stress Level:

What therapies do you use regularly?

Blood Pressure: (for practitioner only)

Please add any information on operations/surgeries in the last 5 years

Medications and nutritional supplements used on a daily basis;

Time

Hour Minutes

AM/PM Option

Breakfast:

Time

Hour Minutes

AM/PM Option

Lunch:

Time

Hour Minutes

AM/PM Option

Dinner:

Snacks:

I confirm that I have provided, to the best of my knowledge and ability, the relevant information about my health and lifestyle.

I agree to receive Colon Hydrotherapy from XYZ and to inform my therapist of any relevant changes in my health and lifestyle. I have understood the treatment that I am consenting to and confirm that I have no reason to consult with my GP before undergoing the treatment.

Signature

Date

DayMonthYear

Colonic Hydrotherapy Consultation Form

Patient Information

Medical History

Colonic Irrigation Treatment Consent Form