Holistic Health QuestionnaireInterested in our services? Fill out the form below before your visit, and we will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Email * Phone (###) ### #### What services are you interested in? Colon Hydrotherapy Bio-Electric Lymphatic Treatment IV Therapy Body Contouring Post-Op Recovery treatment PRP - Platelet Rich Plasma Joint Injections Telehealth Occupational Health (Physical, TB, Respirator Fit) Lab / Gut Diagnostic Testing Medical Weight Loss What is your budget? How did you hear about us? Option 1 Option 2 Occupation Birthdate Are you under a doctor's care? * Yes No If so, what are you being treated for? Doctor's Name, Office Location, and Phone # Medications * Supplements Have your received a colonic before? If yes, when? * Yes No Have you received lymphatic drainage before? If yes, when? * How many bowel movements do you have per day? * Are you currently pregnant or could you potentially be pregnant? List all physical complaints * List all surgeries (type and date concluded) List all allergies * What are you hoping to achieve today? What are you hoping to resolve? Please check any of the following health conditions that apply to you * Congestive heart failure Recent colonoscopy (at least 12 days post colonoscopy) Severe cardiac disease e.g. uncontrolled hypertension Tumor in the rectum or large intestines Aneurysm (active or chronic history) Renal insufficiency Anticoagulants (blood thinners) Kidney dialysis - End Stage Renal Disease Severe Anemia Active internal bleeding HIV / AIDS GI hemorrhage / perforation GI band / Gastric bypass / stomach surgery Hemorrhoids Epilepsy Ulcerative colitis History of seizures Crohn's disease Miscarriage (less than 4 months post-op) Diverticulitis Breast feeding Abortion (less than 6 months) Cirrhosis Hepatitis A, B or C Pregnancy Colon, Rectal or stomach cancer Compromised Immune System Fissures or fistulas Present infections Abdominal or inguinal hernias Rectal bleeding Colon surgery Abdominal pain Recent abdominal surgery (at least 3 months post surgery) Active vomiting Recent hernia surgery Take medication to control diabetes Take medication to control blood pressure Any issues urinating? None For Bio Electric Lymphatic Drainage * Electrical implant of any kind Pacemaker Recent surgery Pin, staples, metal plates Auto accident, falls, any other trauma to the body? Please Explain anything checked above and the last occurrence How did you hear about us? Facebook Instagram TikTok Yelp Google Search Family or Friend Who referred you? By completing this questionnaire, I agree to the following 24 hour cancellation policy Yes No Thank you!
