Colonic Confidential Client History Form

Step 1 of 5

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Name(Required)

Title First Last

Address(Required)

Street Address Address Line 2 City County Post Code

Email(Required)

Phone(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Occupation(Required)

What did you hear about us?(Required)

GP's Name and Address(Required)

GP’s Name and Address Address Line 2 City County Post Code

Are you seeing your doctor at present?(Required)

Yes

Please give details

List any medications, supplements you are taking

List any medical conditions you have

List any surgical procedures you have had and the dates?

List any allergies you may have

Do you suffer from any of the following?

Hernia

Cancer of the colon or rectum

Colitis

Congestive heart disease

Diverticulitis

Fistula

Hirschsprung’s disease

High Blood Pressure

Ileus (paralytic)

Ulcerative Colitis

Crohn’s

Inflamed haemorrhoids

Rectal bleeding

Renal insufficiency

Severe persistent diarrhoea

Controlled high blood pressure

Diabetic

Low Blood Pressure

Fissure

Severe Anaemia

Haemorrhoids

Radiotherapy of abdominal area not discharged from medical care

Have you ever had surgery of colon or rectum?(Required)

Yes

When?

Have you ever had a bowel biopsy?(Required)

Yes

When?

Have you a prostate biopsy made through the bowel?(Required)

Yes

When?

Have you had abdominal surgery e.g. hysterectomy?(Required)

Yes

When?

Recent laparocoscopy?(Required)

Yes

When?

Are you undergoing chemo-therapy and cancer treatments?(Required)

Yes

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

Yes

Are you pregnant?(Required)

Yes

Are you breastfeeding?(Required)

Yes

General Bowel Movements

Do you require laxatives?(Required)

Yes

What do you take?

How would you describe your bowel movements?(Required)

Less than a once a week

Once a day

After eating

Ocassional

Twice a day

Require straining

Other

Give details

Do you suffer from any of the following?

Diarrhoea

Constipation

Gas / Wind

Bloating

Declaration 1(Required)

I consent to all the below

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
I consent to the data I have given to be used by eternalbeing for the purposes of documenting and communication in regards to the treatment I am undertaking.
I consent to the data I have given to be used by for the purposes of documenting and communication in regards to the treatment I am undertaking.
Only information to my treatment will be held and it will be stored for no longer than necessary
My data will not be passed to any third party without my consent.

Declaration 2

I’m happy to receive any information on promotions and / or newsletters

I consent to being contacted by

Phone

Text