Consultations

Consultation Form

Please call our office at (888) 489‐3438 or (310) 350-5053 to schedule your consultation. The following form is to be completed at least 24 hours prior to your consultation. If you prefer to print this form and fax it to us, please print this page, or click here to download and print.

Health History Questionnaire

Personal Information

Family History

MOTHER HISTORY




FATHER HISTORY




Habits
CoffeeTeaSugarChocolateAlcoholCigarettesDrugsLaxatives



Please describe what you are currently eating for...

Health Check List

Digestive Tract:
NauseaDiarrheaConstipationBloatingBelchinExcess GasHeartburn
Ears:
Itchy EarsEarachesEar Infectionsear DrainageRinging in EarsHearing Loss
Emotions:
Mood SwingsAnxietyNervousnessanger/IrritabilityDepression
Energy:
FatigueApathyLethargyHyperactivityRestlessness
Eyes:
Watery EyesItchy or Red EyesBlurred VisionTunnel Vission
Heart:
Irregular heartbeatRapid heartbeatChest pains
Joint/Muscle:
Joint painArthritisMuscle painVaricose veins
Head:
HeadachesDizziness
Lungs:
Chest congestionAsthmaShortness of breath
Mind:
Poor memoryConfusionLearning
Disabilities:
StutteringPoor concentration
Mouth/Throat:
Chronic sore throatSwollen gumsCanker soresSensitive teeth-nerves
Nose:
Stuffy noseSinus problemsHay feverSneezingExcess Mucus
Skin:
AcneHives or rashesHair lossExcess sweating
Weight:
Binge eatingCravingsExcessive weightCompulsive eatingWater retentionUnder-weight
Others:
Frequent illnessFrequent urinationGenital itchGenital Discharge

From the following list, what do you believe might be causing your fatigue?

Airborne?Food?Poor Sleep Habits?Thyroid?Stress?

Have you had previous Colon cleansing sessions with a professional colon Hydrotherapist?


Are you currently doing colonics or enemas now?


Metabolic Assessment Form

Please choose on a scale of 1 – 4 the appropriate answer to each question below.
CATEGORY I – COLON
Feeling that bowels do not empty completely:1234

Lower abdominal pain relief by passing stool or gas: 1234

Alternating constipation and diarrhea: 1234

Diarrhea:1234

Constipation: 1234

Hard dry or small stool:1234

Coated tongue of “fuzzy” debris on tongue:1234

Pass large amount of foul smelling gas: 1234

More than 3 bowel movements daily: 1234

Do you use laxatives frequently:1234