The North East’s Expert in Colonic Irrigation, Food Intolerance Testing and Digestive Consultancy

Digestive Health Medical Questionnaire

We cannot carry out your treatment without this form.

Please ensure that all mandatory(*) fields and any applicable optional fields are completed and click Validate at the bottom. Any missing information will be highlighted for your information.

Name & Address

Personal Details

Doctor

Lifestyle




Reasons for Treatment:

Select how long each condition has lasted

Eating Habits and Lifestyle:

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

Please describe your levels of stress

Please describe your typical workday eating pattern, including meals,snacks and liquid intake.

Please describe how much you smoke.

Please describe how much alcohol you drink.

Please provide details any use of recreational drugs.

Medical Conditions

Do you have any of the following conditions? (Please tick all that apply):

Normal Bowel Habits

Do you find any of the following in your faeces:

Do you ever have to:

Medication

Have you ever taken any of the following medications for an extended period? Is so say when and what for:







Cravings

Do you crave any of the following?



Women Only

Do you currently have or have you ever had:

Men Only

Do you currently have or have you ever had:

Contra-indications

The following is a list of contra-indications for colon hydrotherapy treatment – please ensure you tick all that apply:

Candida Health Check

Tick all of the statements that apply to you.

Operations & Surgeries


Medications & Nutritional Supplements


Additional Information


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