Client Questionaire
Client Questionaire
Inner Garden Health
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Email
Phone
-
###
-
###
####
Cell
-
###
-
###
####
Birthdate
/
MM
/
DD
YYYY
Male
Female
Other
How did you find us?
friend
internet
doctor
other
Is this your first Colon Hydrotherapy session?
yes
no
If no, what was the date of your last session
Contraindicated for Colon Hydrotherapy sessions. Please check if you have any of the following now or in the past
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/Hiv
YOU MUST CALL IF YOU CHECK ANY OF THE ABOVE 604-737-1161
Do you have any of the contraindication listed above?
*
Yes
No
Yes, in the past
Please explain and advise dates of the above diagnosis
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 do you usually have ?
0
1
2
3 or more
Do you strain to have a movement?
yes
no
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
If you have breakfast, what do you eat?
What do you eat for lunch?
What do you eat for 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
*
I agree with Inner Gardens Cancellation Policy