Colonic Irrigation Health Questionnaire

1 About You

2 GP Details

3 Medical Details

4 Past/Current Illnesses

5 Toilet Habits

6 Diet

7 General Health

8 Gastrointestinal Health

9 Physical Health

10 Other Health

11 Declarations

Name*
Prefix First Last
Address*
Street Address Address Line 2 City County Postcode
Phone Number*
Email*
Date of Birth*
Age*
Weight*
Height*
Occupation*
Do you have any children?*
- Yes
- No
If yes, how old are they?
Please enter the age of any children you have, separated by a comma if more than 1
Do you have any pets - cats, dogs etc.? If so, please list*

Do you crave any particular type of food and if so what?*
How many cups of tea and/or coffee do you drink a day on average?*
Do you add sugar to your hot drinks and if so, how much?*
Do you drink soft drinks (cola etc.) and if so, how many per day on average?
How many glasses of water do you drink each day?*
Do you have a good appetite?*
- Yes
- No
Do you suffer from any food allergies/food sensitivities?*
If yes, please list. If not, please enter 'no'
Daily diet – please give an indication of your typical daily diet
Breakfast*
Mid-morning*
Lunch*
Mid-afternoon*
Dinner*
Have you ever suffered from anorexia or bulimia?*
- Yes
- No
Do you ever over-eat?*
- Yes
- No
Are you vegetarian or vegan or neither?*
- Vegetarian
- Vegan
- Neither
Do you feel that certain foods upset you and if so, which?*
Please give any other information you may think is relevant about your diet

What do you think needs to change to improve your health?*
List your main reasons for wanting Colon Hydrotherapy*
How did you hear about Gedling Colonics?*
If other please give details
Declarations
The information provided above is, to the best of my knowledge, true and accurate. I also confirm that I have not with-held any health/personal information that may affect the therapist's decision to treat me with colon hydrotherapy.*
- I confirm the details are correct to the best of my knowledge
I agree to having a rectal examination if during discussion it is deemed necessary*
- Yes
If suffering from diabetes, angina, heart disease or epilepsy, in the event of an attack, I agree to the following action being taken (select as appropriate):*
- Administer my medication
- Call an ambulance
- Call relative
- Position comfortably
Please type your name below to digitally sign this document*
Today's date*

DD
MM
YYYY
Verification

Health Questionnaire