Client Information & Medical History

In order to provide you with the most appropriate session, we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY

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Client Name

Today's Date

Date of Birth

Age

Gender(required)

Male Female Prefer not to say

Occupation

Home Address

City

State

Zip Code

Mobile Phone

Emergency Contact Name and Phone

How were you referred to Move Colonics?

Are you currently under the care of a physician?(required)

Yes No

If Yes, for what?

Have you ever had a Colonic?(required)

Yes No

If Yes, when and where?

Please initial to confirm that you have read and understood all of the contraindications for Colon Hydrotherapy. Since the therapist is not licensed to diagnose disease states, I, the client, take full responsibility for the status of my health and choose freely to go ahead and have a colonic session performed. I, the client, also agree to let the therapist know of any changes to my health status with regard to future bookings (initial below):

List any other cleansing experiences you've had:

List any medications you are taking:

List any supplements you are taking:

List any allergies you have:

List any serious illness/hospitalizations/injuries:

What is your chief health concern?

How often do you have a bowel movement?(required)

Daily Every 2 to 3 days Every 3 to 5 days

How many bowel movements per day (on average) do you have?

If Other, please explain:

What would you say the transit time (the time it takes for a meal to pass through your digestive tract) is for you?(required)

What is the usual color of your stool?

Do you use laxatives?(required)

Yes No

If Yes, what types?

Do you have hemorrhoids?(required)

Yes No

Have you had rectal bleeding?(required)

Yes No

Have you ever had any of the following?

Are your menstrual cycles regular?

Yes No

Do you presently use birth control?

Yes No

Have you ever used birth control?

Yes No

If Yes, for how long?

Have you ever had tubal ligation?

Yes No

Have you ever had a hysterectomy?

Yes No

Are you now, or is there any possibility that you are pregnant?

Yes No

Are you trying to conceive?

Yes No

Do you have any children?

Yes No

How many glasses or ounces of water do you drink daily?

If Other, please explain:

Current weight in pounds (lbs):

Desired weight in pounds (lbs):

What is your blood type?

A AB B O

Do you sleep well?(required)

Yes No

How many hours of sleep do you get a night (average)?

What are your stress levels?(required)

Low Moderate High

Do you exercise regularly?(required)

Yes No

If Yes, how many times a week?

What would like to receive from this appointment for Colon Hydrotherapy?

How apt are you to make changes to your diet and lifestyle for your health?

Ready to put my health first. Open to changes. I do not want to change.

Would you like a silent session or prefer to talk?

Signature

Date

Please initial below to confirm that you are physically & emotionally fit to do a colonic.

Please initial below to confirm that you understand that packages expire within Three (3) months of purchase.

Please initial below to confirm that you understand there are no refunds for any reason, and you will be charged if you cancel less than 24 hours in advance.

Move Colonics | Minneapolis/St. Paul Colonics | Colon Hydrotherapy

Colon Hydrotherapy, or colonics, available in Minneapolis/St. Paul, Minnesota.

Client Information & Medical History

PERSONAL HISTORY

Your message has been sent

PERSONAL HISTORY

Your message has been sent

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