Health Questionnaire

This questionnaire must be completed prior to your first colonic treatment

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Please complete the form below prior to your first colonic irrigation health consultation. The required information is securely and directly sent by email to Gedling Colonics. All information is handled in strictest confidence.

For a print version of this form to complete and bring along to your appointment, please click here.

 

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
  • Please enter the age of any children you have, separated by a comma if more than 1