Client Intake Form

Health History Questionnaire for Colon Hydrotherapy. Please answer all questions.

Your Information

Name *

Cell Phone *

Work Phone

Address

City

State

Zip

Email *

Occupation

Height

Weight

Birth Date *

Age *

Are you under a Physician's care?

Physician Name

Type

Emergency Contact

Relation

Phone

Mandatory

What is a Contraindication?

(con·tra·in·di·ca·tion) A contraindication is a specific health condition in which a Drug, Disease, Procedure, Treatment or Surgery is inadvisable, as it may be harmful to the health of the client/patient.

Contraindications: Enter the date if you have ever had any of the Following

Abdominal HerniaAbdominal SurgeryAbnormal DistensionAcute Liver FailureAnemiaAneurysm - All TypesCancerCardiac ConditionCrohns DiseaseColitisDialysis PatientDiverticulosis/DiverticulitisFissures & FistulasHemorrhagingHemorrhoidectomyIntestinal PerforationsLupusPregnantRectal / Colon SurgeryRenal Insufficiencies

Important — Please Read

If you have any of the contraindications listed above, you must get a signed letter from your doctor before you can receive a colonic.

Please Check

Other Health Concerns

These are not contraindications. Please check anything that applies to you.

Hemorrhoids - InternalHemorrhoids - ExternalRectal / Blood in StoolRecent ColonoscopyUse LaxativesBM Painful / DifficultBurning / Itching AnusConstipation / DiarrheaVomitingBloatingHigh Blood PressureInfectious DiseaseAllergic to LatexBladder Infection

Date of Last Menstrual

Other

I have NOT been diagnosed with any Contraindications for colon hydrotherapy.

Client Initials *

READ AND INITIAL:

I am aware that this Center uses FDA Colon Hydrotherapy Device(s) and the Trained Therapist is not required to be State Licensed. This Center does have a Licensed Medical Director that may NOT be on site. No studies have been conducted for this alternative and complementary modality. I am aware adverse events such as perforation, injury and illness have been alleged and claimed with the use of colon hydrotherapy devices and/or enema kits.

Should I experience resistance during my nozzle insertion, I will immediately stop my session.

If during the session I experience discomfort or pain, I am responsible for immediately stopping my session. If you are taking medications that may increase the risk for potential side effects, then you should consult with your physician before proceeding with your colonic.

I have read and understand my responsibilities for colon hydrotherapy sessions.

Client Initials *

I have reviewed and discussed with the LIBBE Device Trained Therapist that I do not have any Diseases, Contraindications or other Health Concerns and I wish to proceed with my colon hydrotherapy sessions.

Type your full name as signature *