Client Questionaire

Inner Garden Health

Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone - ### - ### ####
Cell - ### - ### ####
Birthdate / MM / DD YYYY
How did you find us?

friend internet doctor social shopper Other
Is this your first Colon Hydrotherapy session?
yes no
Contraindicated for Colon Hydrotherapy
Severe Cardiac Disease Aneurysm Severe Anemia GI hemorrhage/perforation Severe Diverticulitis Ulcerative colitis Crohn's disease Cirrhosis 1st trimester of pregnancy Advanced pregnancy Abdominal hernia Recent colon surgery Renal insufficiency Fissures/fistulas Chemo/radiation treatment Cancer Aids Please call if yes to any of the above
What, if any, is your prior experience with cleansing, other then colon hydrotherapy?
Juicing Herbal Cleanse Health Spa
What results would you like to see from your sessions?
Please indicate any intestinal related procedures you have had.
Barium enema colonoscopy sigmiodoscopy other
How many bowel movements per day?
How many bowel movements in a week?
Do you strain to have a movement?
Please check applicable responses:
mucus in stools Blood in stools strong odor
Which of the following applies to you:
Allergies Anemia Anorexia Anxiety Appendicitis Asthma Auto Immune disorder Binging or bulimia Cancer Candida albicans Chemical toxicity Cholesterol/ high Cholesterol/low Chronic fatique Depression Dizziness Eating disorder Edema Environmental sensitivities Extreme weight gain or loss Fainting Fatigue Fibro/polymialgia Headaches or migraines Heart condition High or low blood pressure Kidney stones Liver disease Low blood sugar Low libido Lung disorder Lupus Lyme disease Metal poisoning Menopause Mental disorder Nerve disorder PMS Pregnant ? Prostate condition Renal insufficiency Sinus condition Skin condition Spleen or pancreas problems Sweats Thyroid problems Toxicity Tumors Ulcers Urinary tract infection
Have you recently been diagnosed with a major illness?
yes no
Which of the following apply to you?
Abdominal Gas anal discomfort or itching Anal/rectal bleeding Appendicitis Bad Breath Belching/ Bloating Carcinoma Celiac Disease Colitis Constipation Cramping Crohn's Diverticulitis/osis Diarrhea Fatigue after Eating Fissure Fistula Gallstones Hemorrhoids Hernia Hungry all the Time Indigestion Irritable Bowel Syndrome Lactose Intolerance Nausea Parasites Polyps Poor Appetite Prolapsed Colon Acid Reflex/Heartburn Spastic Colon Vomiting Other
Do you use any of the following?
Antibiotics Prescription drugs Over the counter drugs Recreational drugs Prescription drugs antidepressants
Please list all supplements
Rate your stress level on a scale of 1 to 10. ( 10 = totally stressed out)
How many glasses of water do you drink daily and what kind of water?
Which of the following typically describes your diet?
Raw Foods Whole Foods Dairy Meat Vegan Vegetarian Standard American Diet Fast Food Ketogenic
check the foods you eat regularly
Poultry Fish Red Meat Eggs Cheese Milk Soda Green Vegetables Bread Coffee Desserts Nuts/Seeds Organic Foods Alcohol Yogurt/ Kefir Beans Fruit Processed Foods Soy Chocolate Pasta Protein Shakes or Smoothies Flax or Chia Seeds Sugary Candy Coconut Oil Olive Oil Butter Other
Your typical breakfast, lunch, and dinner.
Please list any food alergies.
Do you often get tired after eating?
Yes No
Do you shake, get light headed or anxious when you miss a meal?
Yes No
Cancellations are accepted with 24 hours notice. Clients are responsible for full payment of missed sessions *