COLON THERAPY HEALTH FORM

Name____________________________________

Date of birth_________________ Phone ____________________

Address_____________________________________

City / State / Zip_______________________________

Email Address_______________________ (used for quarterly newsletter 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 (for current conditions):

Anal Fissure / Fistula YES____ YEAR____

Aneurysm (abdominal) YES____ YEAR____

Bowel Impaction/Obstruction YES____ YEAR____

Colon Cancer YES____ YEAR____

Colon Surgery (less than 6 mo. Ago) YES____ YEAR____

Colostomy YES____ YEAR____

Crohn's Disease YES____ YEAR____

Dysentery YES____ YEAR____

Gastroenteritis YES____ YEAR____

Hemorrhoids (Painful or Bleeding) YES____ YEAR____

Hernia (unrepaired abdominal / inguinal) YES____ YEAR____

Kidney Dialysis YES____ YEAR____

Pregnancy (current) YES____ YEAR____

Rectal Bleeding YES____ YEAR____

Surgery (abdominal, colon, or rectal - < 6 mo) YES____ YEAR____

Terminal Illness YES____ YEAR____

Ulcerative Colitis YES____ YEAR____

WITH PHYSICIAN REFERRAL:

Colitis YES____ YEAR____

Acute Diverticulitis YES____ YEAR____

Severe Diverticulosis YES____ YEAR____

Irritable Bowel Syndrome YES____ YEAR____

OTHER HEALTH CONCERNS:

Adhesions YES____ YEAR____

Allergies YES____ YEAR____

Anorexia / Bulimia YES____ YEAR____

Bloating YES____ YEAR____

*Blood Pressure __High __Low YES____ YEAR____

Cancer YES____ YEAR____

Candida YES____ YEAR____

Chronic Fatigue Syndrome YES____ YEAR____

Constipation YES____ YEAR____

Diabetes YES____ YEAR____

*Diarrhea YES____ YEAR____

Gas / Flatulence YES____ YEAR____

Fibromyalgia YES____ YEAR____

Headaches YES____ YEAR____

*Heart Problems YES____ YEAR____

Hepatitis YES____ YEAR____

Hypoglycemia YES____ YEAR____

Injuries, recent YES____ YEAR____

*Kidney Problems YES____ YEAR____

Leaky Gut Syndrome YES____ YEAR____

Osteoporosis YES____ YEAR____

Parasites YES____ YEAR____

Polyps YES____ YEAR____
Skin Problems YES____ YEAR____

Stomach Problems YES____YEAR____

Surgeries YES____YEAR____

Other (explain)_________________

* No Salt/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 client's 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.

*****************************************************************************************************

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 WEEKDAY HOURS 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 ________________________