Digestive Health Medical Questionnaire ›› Vibrant Feeling Clinic

Name & Address

This name and address information is populated from your initial registration or previous forms. Any changes made will be updated for future forms.

Title:*

Forenames(s):*

Surname:*

Address 1:*

Address 2:

Town:*

County:*

Postcode:*

Email:*

Mobile:*

Personal Details

Gender:*

Date of Birth:*

Doctor

Doctor's Name:*

Surgery Name:*

Surgery Address 1:*

Surgery Address 2:

Surgery Town:*

Surgery County:*

Surgery Postcode:*

Lifestyle

Height (Feet & Inches):*

Weight (Stone & LBs):*

Marital Status:*

Children:*

Occupation:*

Exercise:*

Do you take vitamins/minerals?*

Reasons for Treatment

Kick-start / Maintain Health
Detox
Help with Weight Loss
Increase Energy

Irregular Bowel Movements*

Constipation*

IBS / Bloatedness*

Diarrhoea*

Food Cravings*

Mood Swings*

Yeasts / Candida*

Skin Problems*

Allergies*

Do you have a latex allergy?*

Yes
No

Parasites*

Headaches / migranes*

Eating Habits and Lifestyle:Tick the statements that apply to your eating habits and lifestyle*

Levels of Stress: Please describe your levels of stress*

Workday Eating Pattern: Please describe your typical workday eating pattern, including meals,snacks and liquid intake.*

Smoking: Please describe how much you smoke

Drinking Alcohol: Please describe how much alcohol you drink

Recreational Drugs: Please provide details any use of recreational drugs.

Have you ever had mercury fillings?*

Yes
No

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:

Blood
Mucus

Do you ever have to:

Strain
Take Laxatives

Have you every consulted your GP due to any bowel problems?

Yes
No

Do you have Bowel Movements*

Have you ever or do you still experience feeling faint , dizzy, nauseous when you are on the toilet when going for a number 2?*

Yes
No

Details

Have you ever had a colonic?*

Medication

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

Antibiotics:

Cortisone:

Diuretics:

Steroids:

Heart Drugs:

Any Others:

Cravings – Do you crave any of the following?

Sweet Things
Coffee
Nicotine
Alcohol
Salty Things
Tea
Chocolate

Anything Else:

Are there any foods that you find hard to digest? What are they?:

Women Only – Do you currently have or have you ever had:

Pre-menstrual tension
Any sexually transmitted disease
Pelvic inflammatory disease
Menopausal symptoms
Cervical erosion
Any problems with your periods
Thrush or other vaginal discharge
Are you pregnant?

Men Only – Do you currently have or have you ever had:

Thrush
Cystitis
Prostate problems
Vasectomy
Any sexually transmitted disease

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 the questions that you answer yes to.

Operations & Surgeries – Please add any information on operations/surgeries in the last 5 years:

Medications & Nutritional Supplements – Please list any medications and nutritional supplements you take on a daily basis:

Additional Information – Please list below any further information about your health that you feel may be of importance to your treatment – if you would prefer to discuss this with your therapist in advance please call:

Where did you hear about us?*

Signature:*

You must sign – this is a legal requirement.

Comments

This field is for validation purposes and should be left unchanged.

Medical Questionnaire

Medical Questionnaire

Digestive Health Consultancy Consent Form

Name & Address

Personal Details

Doctor

Lifestyle

Medication

What a Typical Appointment Includes

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