Sara Hunt - Priority Health
Priority Fitness & Health - Waukee, IA
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HEALTH QUESTIONNAIRE

Name:____________________________________Email_________________________________________

Address:______________________________________________City______________________________

State________________________________________Zip________________Birthdatep_______________

Phone: (Home)______________________(Work)______________________(Cell)_____________________

Occupation:_____________________________Weight:________ Marital Status:____________ M/F_____

Supplements____________________________________________________________________________

Allergies________________________________________________________________________________

* Have you ever had Colon Hydrotherapy before: ________
* If Yes, when and where? ________________________________________________How Many?_______
* Do you use any of the following? Laxative ________ Enemas_____________ Antacids_____________
* Are you presently taking any medications?______ If yes, give detail
________________________________________________________________________________________

________________________________________________________________________________________

*Have you been hospitalized in the last year? ___________  If yes, give details

Do you have any contagious diseases now? ___________ Please list all
________________________________________________________________________________________

Do you have history of colon cancer in your family?_________________   Are you pregnant?_________

Your Physician's name and address: 
_______________________________________________________________________________________

Please briefly describe reasons you are choosing colon Hydrotheraphy:

__ Constipation   __Bloating  __ Gas Pain  __ Diarrhea   __ Colitis ___Cleansing ___Illness

How often do you have a bowel movement?_______________ Last time you had a BM?_____________

SOURCE OF REFERRAL: __________________________________________________________________

AGREEMENT (Please read and sign):

The practitioner giving me a Colon Hydrotherapy Treatment does not provide medical services of any kind.   Clients are expected to seek and use such medical services as may be required from a physician.   The service of Colon Hydrotherapy is not designed to diagnose, treat or cure any disease or medical condition.   Any medications or other supplementation prescribed by your physician should be continued.   I agree that I have read and understand the above statement.   All the information given by me, the client, here is true.

CLIENT'S SIGNATURE _______________________________________________Date__________




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