Health Questionnaire for Colon Hydrotherapy Please download, read, sign, and bring in this form with your next visit. Click Here HEALTH QUESTIONNAIRE FOR COLON HYDROTHERAPY SESSION: First Name * Last Name * Email Address * Address * City * State * Zipcode * Country * — Select Country —UNITED STATES Phone Number * Referred By Date of Birth * Are you currently under a medical doctor’s care? If yes, please explain Doctor’s name Telephone Are you pregnant? YesNo List all known allergies. List all medications (including over the counter). What do you hope to achieve from this appointment? Please check whether you have or had any of the following: — Please select —Severe Cardiac DiseaseUlcerative colitisRecent colon surgeryAneurysmCrohn’s diseaseRenal insufficiencySevere AnemiaCirrhosisFissures / FistulasGI hemorrhage/perforation1st trimester of pregnancyChemo/Radiation TXSevere HemmorhoidsAdvanced PregnancyCancerSevere DiverticulitisAbdominal HerniaAids If answered yes to any, please explain. Have you had recent surgeries? If yes, please explain. Are you currently taking the following medications: Coumadin, Heparin, Plavix (blood thinners)? I have honestly answered all above questions and am not intentionally withholding information about my health. YesNo