Ealing Natural Therapies – Colon Hydrotherapy Client Detail Form

Full name:			DOB:
Address:
Telephone (home):		Telephone (work):
GP name & address:
Marital status:	Number of children:			Occupation:

Please list any medications you are taking:

Past medical problems & dates:

Past surgical procedures & dates:

How many courses of antibiotics you have taken in your life?

Are you seeing any other practitioners at present? (please list with brief description of treatment):

Please list vitamin & mineral supplements being taken:

Please list any herbs and/or homeopathic remedies being taken:

Do you have any of the following (please tick next to item if appropriate):

High blood pressure

Heart problems

Renal problems (kidney and/or bladder)

An abnormal hernia

Haemorrhoids

Cirrhosis (of the liver)

Are you H.I.V positive?	If so are you diagnosed with A.I.D.S?
Do you smoke?	If so how many per day?
Do you drink alcohol?	If so, how much per week?
Do you eat sweets?	If so, how many And how often
Do you drink tea?	If so how many cups per day?
Do you drink coffee?	If so, how many cups per day?
Do you exercise?	How often?
Do you have regular bowel movements (please describe)?

Do you have any allergies (please list & describe any reactions you have experienced)?

Do you have a family history of any of the following conditions (please tick if relevant):

Crohn’s disease

Ulcerative Colitis

Heart disease

Cancer

Diabetes

Is Their Anything further not yet mentioned that you feel is relevant?

Signed: Dated: