Health Discovery Consultation & Holistic Colon Hydrotherapy

Health Discovery & Colon Hydrotherapy

Consultation Form
Title (Mr/Mrs/Miss)*
Name*

First NameLast Name
Phone*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email *
Occupation*
Date of Birth*
How did you hear about us?*
Have you had a Colon Hydrotherapy treatment before?*
Reason(s) for contacting us*
More Details:
Have you participated in a cleansing/detox program? If yes; please specify*
Digestive System Health
How much water do you drink? (Litres / Oz)*
Weight (kg / lbs)*
Do you eat/drink any of the following*

Red MeatWhite MeatFishDairyBreadWheatYeastSugarFruitVegetablesAlcoholCarbonated drinksEggsNutsCoffee
What types of things have you had for BREAKFAST over the past 30 days?*
What types of things have you had for LUNCH over the past 30-60 days?*
What types of things have you had for DINNER over the past 30-60 days?*
What kinds of SNACKS do you eat and what TIME of day do you eat them?*
What time do you eat your first meal for the day?*

:HourMinutesAM/PM Option
What time do you eat your LAST meal/snack for the day?*

:HourMinutesAM/PM Option
Do you take supplements, Probiotics or Naturopathic Herbs? Please Specify*
How frequent are your bowel movements*

Irregular1 per day2-3 per day1 per week2-3 per week4 per week
Are your bowel movements painful or difficult?*
SELECT current or past conditions*

AllergiesAbdominal ProblemsAnxietyArthritisAsthmaCirculatory ProblemsDepressionCancer of the colonDiabetesDigestive ProblemsStressProlapsed ColonBack AcheHearing ProblemsStrokeProsthesis or DenturesHeadachesHeart ProblemsHistory of SeizuresLow Blood PressureMigraine HeadachesGall Bladder ProblemsIrritable Bowel SyndromeAccident/TraumaHigh Blood PressureKidney ProblemsTumorsChronic FatigueCandidaChronic PainMenstrual Pain /ProblemsCirrhosis of the LiverMuscle/Bone InjuriesSkin ProblemsFlatulenceMuscle/Joint PainVisual ProblemsPhlebitisNumbness/TinglingWeight ProblemsRash/Athletes Foot/TineaParasitesPCOS / Ovary concernsHair LossAuto ImmuneOther
Please list any health conditions in your family - especially your Parents & Grandparents
eg.Digestive Issues, Liver Cancer, Diabetes etc
Select ANY of the following that apply to you*

Mercury/Metal Dental FillingsBladder InfectionBloatingBlood in stoolBurning/Itching anusConstipationContraceptiveDiarrhoeaHaemorrhoidsRectal BleedingRecent Barium EnemaRecent ColonoscopyBowel StrainVomitingOther
Contraindications Select ANY of the following that apply to you*

Abdominal HerniaAbdominal SurgeryAbdominal DistensionAcute Liver FailureAnal Fissures & FistulasAnemiaAneurysmCancer of the colonColitis Active or BleedingCrohns DiseaseCardiac ConditionsDiverticulosos/DiverticulitisHaemorrhoidectomy SurgeryHemorroids (Severe or Bleeding)High Blood PressureIntestinal PerforationsKidney DialysisLupusPregnantRectal/Colon surgeryRectal BleedingRenal InsufficienciesSteroid MedicationsNone
Please list any medications you currently take or have taken in the past 6 months
General Health
Do you have regular sleep patterns?*
Do you have any infectious diseases?*
Do you smoke? How many per day?*
Do/Have you taken recreational drugs?*
Do you exercise*

Never1 day per week2-3 days per week4-5 days per week7+ days per week1-2 days per month
Height*
Emergency Contacts
Emergency Contact Name
Emergency Contact Phone
Doctors Name
Doctors Phone
Health & Wellness Goals
Please list your 3 health & wellness goals
Terms and Conditions
Accept Terms

I confirm that the information above is correct and that to my knowledge I have not withheld any information that may be relevant to my consultation. By ticking this box you acknowledge that wellness coaching & or colon hydrotherapy is not intended to replace the relationship with your primary health care providers. My consultation with a Colon Hydrotherapist or Wellness Coach is not intended as medical advice. If I experience pain or discomfort after the session, I will immediately inform Havana Wellness so that a followup appointment or call can be scheduled asap. I will not hold Havana Wellness or my coach responsible for any affects within my body after any wellness session. I understand that the services, packages and product purchases are not refunadable. I affirm that I have notified my coach or therapist of all known medical conditions, medications and injuries. I agree to inform my coach or therapist of any changes in my health and medical condition. I understand that there shall be no liability on the coach or therapist’s part should I forget to do so. By signing this release, I hereby waive and release my coach, therapist and Havana Wellness from any and all liability, past, present, and future relating to colon hydrotherapy, detox, cleansing protocols and bodywork. I understand that a follow up session for colon hydrotherapy is advised within 24hrs and if an appointment is not available an enema kit is available to use at home to assist the body to continue the cleansing process to avoid and assist detox symptoms. I understand that I will require aftercare of wholefood probiotics, and natural electrolytes to support my body (available through Havana Wellness) and wellness coaching is available to me to assist with food choices for digestion in addition to a colon hydrotherapy session.
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Health Discovery & Colon Hydrotherapy

Digestive System Health

General Health

Emergency Contacts

Health & Wellness Goals

Terms and Conditions