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)_________________
Other (explain)_________________
* No Salt/Baking Soda will be used in the cleansing waters.
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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.
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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 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 ________________________