<p> INTAKE FORM</p><p>FULL NAME______</p><p>ADDRESS______</p><p>CITY______POSTAL CODE______</p><p>PHONE: (HOME)______CELL______</p><p>EMAIL ADDRESS______</p><p>DATE OF BIRTH______MALE OR FEMALE______</p><p>OCCUPATION______</p><p>HOW DID YOU HEAR ABOUT US? (PLEASE CIRCLE BELOW)</p><p>Internet Newspaper Friends Advertisement</p><p>Other (please specify) ______</p><p>What symptoms or health concerns bring you to this appointment?</p><p>______</p><p>Page | 1 List current medications______</p><p>Have you had surgery, or any organ(s) removed? ______</p><p>Contraindications for colon therapy and other digestive disorders, please circle any that apply to you.</p><p>Pregnant IBS Crohn’s Diverticulitis Polyps Gallstones</p><p>Colon Cancer Surgery Hernia Intestinal perforation Heart failure</p><p>Hemorrhoids Colitis Tumors Cysts </p><p>List Nutritional Supplements ______</p><p>Any allergies (please specify) ______</p><p>Do you experience any of the following? (Please circle if it applies to you)</p><p>Bloating Constipation Gas Burping Diarrhea</p><p>Abdominal pain Headaches Back pain Fatigue</p><p>What is your blood type? ______</p><p>Do you use laxatives? What kind? How often?</p><p>LIFESTYLE</p><p>Do you smoke? Y N Water consumption daily______</p><p>Page | 2 Exercise? Y N if so how often______</p><p>FOOD Consumption daily Meat %______Vegetables%______</p><p>Fruit %______Grains/Bread %_____Junk food %______Dairy%______</p><p>BOWEL MOVEMENTS</p><p>How many bowel movements per day? ______</p><p>Do you have to strain to have a bowel movement? ______</p><p>Do you have rectal bleeding? ______</p><p>Have you ever had a Colonic before? ______</p><p>CONTRACT</p><p>Please read carefully</p><p>I, the undersigned, acknowledge that the personnel at Colonic Spa are not prescribing (Ordering for use of medicine) for me at any time, and I will not hold them accountable for such. They are not doctors or responsible for my health choices. Any recommendations I receive are not intended as primary therapy for any symptom of disease, but as means of enhancing the quality of my diet. Any medical problems or illnesses are to be diagnosed by my primary doctor, as Colonic Spa will not do such. I understand the therapist is helping me with natural hygiene at my own risk. </p><p>I understand Colonic Spa has a 24 hour cancellation policy. I understand, if I cancel my appointment without 24 hours notice, I will be charged $50.00.I </p><p>Page | 3 understand, If I do not show up to my appointment, I will be charged the full amount for my treatment. If I have a package, one treatment will be deducted.</p><p>FULL NAME: ______DATE: ______</p><p>SIGNATURE______</p><p>Page | 4 </p>