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A Natural Cleanse, LLCCLIENT INTAKE FORMAll information is kept strictly confidentialName:_____________________________________ DOB:_______________________Date:______________________Address:________________________________________City:__________________State:___________Zip:________Home Phone:___________________Work Phone:__________________________Cell:_________________________Email address:____________________________________________________________________________________Sex: ___Male ___FemaleHeight: _____________Weight:_________________Shoe Size:____________Occupation: __________________________________Hobbies: ___________________________________________All Known Allergies: ______________________________________________________________________________How did you find out about us? _____________________________________________________________________Had Colon Hydrotherapy before? ____Yes ____NoIf Yes, when? ____________ With Whom: ______________Emergency contact: Name: __________________________________ Phone: _______________________________Check One: ___ self-treating ___ Under a doctor’s care, explain: _______________________________________Do you have a prescription today? ____Yes _____No Report my treatment progress to Dr:___________________Do you have family history of colon problems? _________ Please describe: ________________________________Please describe any surgery you have had: ___________________________________________________________Did you have a BM today? ____Yes ____NoHow often do you have a BM? ________________________________Describe your typical BM: __________________________________________________________________________Do you use laxatives? ____Yes ____NoIf yes, what? __________________How Often? _________________Do you use enemas? ____Yes ____NoIf yes, what kind? _______________How Often? _________________Do you exercise? ____Yes ____NoIf yes, what type? _______________How Often? _________________List all over the counter drugs, and prescription drugs you take regularly: list all vitamins, supplements, herbs: (Please describe pills, liquid, extract, tea):_____________________________What are your treatment objectives? ________________________________________________________________Do you have health symptoms you would like to improve? _________________________________________________How to you feel today? _____________________________________________________________________________List foods you have eaten in past 24 hours: Breakfast_________________________________________________Is this your typical diet? _________________Lunch_____________________________________________________Do you eat late at night?_________________Dinner: ___________________________________________________Other: ____________________________________________________How much water do you consume daily? _____________________________________________________________What foods do you crave i.e. Sugar, salt, protein, carbohydrates? ________________________________________Do you sleep well? _______________________________How many hours nightly? ____________________What activities help with stress reduction? ____________________________________________________________How often do you do these activities? ________________________________________________________________I understand that the cost is $100.00 for the first visit, and $80 for return visits? Yes_________ No__________Please turn over and fill out the reverse sideHealth ConcernsIndicate if you have every had any of the following conditions.Present PastConditionContraindication – Who would not be a candidate for colon hydrotherapy treatments? If you have a concern about your health or the appropriateness of colon hydrotherapy you should consult a doctor. If you are diagnosed with lupus diverticulitis, ulcerative colitis, Crohn’s disease, severe, hemorrhoids, rectal or intestinal tumors, have undergone recent radiation therapy, have uncontrolled hypertension, congestive heart failure, or organic valve disease, have an aneurysm, severe anemia, GI hemorrhage/perforation, cirrhosis of the liver, fissures, or fistulas, have an abdominal hernia, have had recent colon surgery or renal insufficiency then you would not be a candidate for colon hydrotherapy treatments, Pregnant women are also advised to only receive colon hydrotherapy during the second trimester of their pregnancy and under the direct supervision and advise from their physician. Professionally administer colon hydrotherapy is generally safe if you are free of the above cited conditions/ contraindications.By signing below, I acknowledge that I have read the above statement.Signature: __________________________-----------------------------------------------------------------------------CONSENT TO TREATMENTBe aware that every therapy, service, and product describe or presented at A Natural Cleanse, LLC is NOT a cure for any disease, ailment, or health condition. NO MEDICAL CLAIMS are expressed or implied, either directly or indirectly, regarding the therapies, products or services presented. We do not diagnose, threat, or prescribe.I ________________________________ agree that the information I documented on this form is accurate to the best of my knowledge. I give A Natural Cleanse, LLC practitioners permission to share information with each other and the prescribing doctor and evaluate and provide colon hydrotherapy. I am aware of and do not have contraindications. I agree to the terms of the client agreement section below. I have read contraindication for colon hydrotherapy section above and I hereby agree that I am responsible for my health and the services received here.____________________________________________Signature:Date: Prescribing Doctor: _________________________Phone Number:____________________________ HepatitisHIV+AIDSLupusAbdominal Gas bloating/DistressAcute fecal impactionAsthmaBladder infectionBlood in stoolConstipationDiabetesDiarrheaFatigueHeadachesHemorrhoids, severeHerniaIrritable Bowel SyndromeIndigestionLeaky Gut syndromeMucus in stoolMuscle/joint achesParasiticPolypsSigmoidoscopy/colonoscopySkin problems“spastic” colon, or “Lazy” colonStrokeAbdomen radiationAcute inflation disease of the colonLiver cirrhosis, fatty liverCarcinoma of the colon or rectumRectal BleedingRenal insufficiencyUncontrolled or untreated Hypertension/High Blood Pressure hypertensionAneurismGastrointestinal hemorrhageCrohn’s DiseaseHeart disease, congestive heart failureCancer or Colon CancerBowel PerforationAbdominal hernia, ulcerative herniaColitis, bleeding, Colon, rectal or abdominal surgeryDiverticulosis/diverticulitisFissures/fistulasKidney disease, insufficiencyPregnantPre/post op surgeryLiposuctionA Natural Cleanse, LLCClient AgreementI have not been diagnosed with any contraindication for colon irrigation (see Contraindication section on intake form). I am aware that colon irrigation and enema devise facilities are NOT physicians and therefore does not INSERT, diagnose, or prescribe. I am aware adverse events such as perforation, injury, and illness have been alleged and claimed with the use of colon irrigation and enemas devises. I am responsible for my own insertion. If I experience résistance during the insertion, I will immediately stop my session. If during the session I experience discomfort or pain, I am responsible for immediately stopping my session. I agree that the information I have given is accurate to the best of my knowledge. I give A Natural Cleanse, LLC permission to share information with the prescribing doctor, evaluate and provide colon hydrotherapy. I am aware of and do not have contraindications. I have read the contraindications for colon hydrotherapy section on the intake form. I hereby agree that I am responsible for my health and the services received here. I am aware of my 9th Amendment Rights to practice alternative health modalities. I confirm that I am 18 years of age or older. Informed ConsentI am not intentionally withholding medical information from the facilitator which is important. I understand the procedure of Colon Hydrotherapy, the devise, and possible side effects which have been explained to me. All my questions have been answered and I agree to participate with this session.DisclaimerEvery therapy, service, and product described or presented at A Natural Cleanse, LLC is NOT a cure for any disease, ailment, or health condition. NO MEDICAL CLAIMS are expressed or implied, either directly or indirectly, regarding the therapies, products or services presented herein. We do not diagnose or prescribe.A NATURAL CLEANSE GUIDELINES AND POLICESFor women on their menstrual cycle: It is perfectly fine to have colonic during menstruation.Please arrive in a calm, relaxed state on time for your appointments. Thank you!To provide you with the best quality service and reasonable prices, I ask that you honor our scheduled appointment time. Your scheduled appointment is set aside for you and you alone. If for some reason you are unable to make your scheduled appointment time, I request at least a 24-hour notice, but would prefer a 48-hour notice. This is so that I might offer this time to another client. Appointments rescheduled or canceled less than 24 hours in advanced will be charged as a missed appointment and billed at a full rate.I appreciate and value the privilege of helping you support your health goals and hope that you understand the reason behind this agreement. If you have any questions or concerns before sessions, please feel free to call.I understand that payment of $100 is due immediately after the first appointment and $80 for returning appointmentsClient Signature:______________________________________________________Date:___________ ................
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