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Colon Therapy Health Form
Name_________________________________________________________________
Date of birth__________________________________ Phone ____________________
Address________________________________________________________________
City / State / Zip_________________________________________________________
Email Address_____________________ (used for quarterly newsletter& 'specials' only)
How did you hear about us?
Word of mouth?___ Advertisement?___ Website?___ Other?___________
Please fill in the information requested below.
**All information will be kept strictly confidential.**
Do you have now, or have you ever had, any of the following? Check if "Yes"
Contraindications With Physician Referral
Yes Year Yes Year
____ _____ Anal Fissure / Fistula ____ _____ Crohn'sDisease
____ _____ Aneurysm ____ _____ Colitis
____ _____ Colon Cancer ____ _____ Acute Diverticulitis
____ _____ Colon Surgery (less than 6 months) ____ _____ Severe Diverticulitis
____ _____ Colostomy ____ _____ Irritable Bowel Syndrome
____ _____ Dysentery ____ _____ Impaction
____ _____ Gastroenteritis
____ _____ Hemorrhoids ( Painful or Bleeding )
____ _____ Hernia ( abdominal / inguinal )
____ _____ Kidney Dialysis
____ _____ Pregnamcy ( Current )
____ _____ Rectal Bleeding
____ _____ Ulcerative Colitis
Other Health Concerns
Yes Year Yes Year
____ _____ Adhesions ____ _____ Headaches
____ _____ Allergies ____ _____ * Heart problems
____ _____ Anorexia / Bulimia ____ _____ Hepatitus
____ _____ Bloating ____ _____ Hypoglycemia
____ _____* Blood Presssure __ High __ Low ____ _____ Injuries, Recent
____ _____ Cancer ____ _____ * Kidney Problems
____ _____ Candida ____ _____ Leaky Gut Syndrome
____ _____ Chronic Fatigue Syndrone ____ _____ Osteoporosis
____ _____ Constipation ____ _____ Parasites
____ _____ Diabetes ____ _____ Polyps
____ _____ * Diarrhea ____ _____ Skin Problems
____ _____ Gas / Flatulence ____ _____ Stomach Problems
____ _____ Fibromyalgia ____ _____ Surgeries
____ _____ Other ( Explain ) ____ _____Other ( Explain )
_______________________________ _______________________________
* No salt or baking soda will be used in the cleansing waters.
Do you take Celebrex, Fosamax, NSAIDs?(circle those you take) YES__ NO__
Allergy to herbs used in Glyco-Thymoline - Carmine, Eucalyptol, Menthol, Pine Oil, and Thymol? YES__ NO__
(If yes, Glyco-Thymoline will not be used in the cleansing waters.)
Approval for the use of Glyco-Thymoline and Salt/Baking Soda in the cleansing waters. YES__ NO__
Do you have an allergic reaction to latex? YES__ NO__
Client requests that the therapist insert the speculum, i.e., the client declines self-insertion of the speculum. YES__ NO__
This request for information does not in any way imply the practice of medicine, or diagnosis of a clients condition by this therapist.
This is to certify that I am requesting services on my own initiative, and I realize that the therapist does not diagnose ailments or prescribe treatments.
This is a hygienic treatment I have requested.
Signature of Client______________________________DATE___________________
The therapist reserves the right to restrict service to, or decline acceptance of any client.
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24 HOUR CANCELLATION POLICY
I UNDERSTAND THAT BY SCHEDULING AN APPOINTMENT WITH LOU UMSCHEID AT THE COLON HEALTH CENTER, I AM ENTERING INTO A CONTRACT TO APPEAR AT A MUTUALLY AGREED-UPON TIME.
• I AGREE TO GIVE 24 HOURS WEEKDAY ADVANCE NOTICE IF I AM UNABLE TO APPEAR FOR MY APPOINTMENT FOR ANY REASON.
• I AGREE TO COMPENSATE THE COLON HEALTH CENTER FOR THE TIME THAT WAS SET ASIDE FOR ME IF I DO NOT PROVIDE SUCH NOTICE.
• I AM AWARE THAT THIS IS STANDARD PRACTICE FOR SMALL PRIVATE PRACTICES AND AM IN ACCORD WITH THE POLICY.
Signature of Client_________________________________Date_________________