Colonics Intake Fill out our form below or PRINT and bring in your intake during your visit. Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressPhone Number *Email Address *Date of BirthHeight and WeightReferralPhone BookNewspaperBrochureSignDoctorGoogleFriendOtherIf Doctor, Friend, or Other, Please Name:Reason for VisitDo you suffer from any of the following?ArthritisAsthmaAllergiesColitisConstipationDiabetesDiarrheaDiverticulitisHeart IssuesHemorrhoidsHeadachesCandidiasisChronic FatigueBad BreathIndigestionBackacheSkin DisordersEye IssuesFoot AchesGastritisRectal BleedingCancerOtherPlease select all that apply.If cancer or other, please explain:Are you pregnant?YesNoSurgeries?X-Rays?ChemotherapyPlease list your medications and supplements:How often do you use AspirinNeverVery rarelyFew times a monthFew times a week1-2 times a day3 or more times a dayHow often do you drink CoffeeNeverVery rarelyFew times a monthFew times a week1-2 cups a day3 or more cups a dayHow often do you use AntacidsNeverVery rarelyFew times a monthFew times a week1-2 times a day3 or more times a dayHow often do you smoke CigarettesNeverVery rarely1-5 times a dayA pack a dayMore than a pack a dayHow often do you drink Black TeaNeverVery rarelyFew times a monthFew times a week1-2 cups a day3 or more cups a dayHow often do you drink AlcoholNeverVery rarelyFew times a monthFew times a week1-2 drinks a day3 or more drinks a dayAre you currently under a doctor's care?YesNoDo you receive chiropractic care and/or massage therapy?YesNoHave you ever had a colonic irrigation?YesNoIf yes, when was your last series and the results?What does your daily diet consist of?How often do you exercise?NeverSometimesOnce a week2-3 times a week4-6 times a weekEverydayHow often do you have a bowel movement?3 times a day2 times a dayOnce a dayOnce every other day1-4 times a weekLess than 4 times a weekWhat is your blood pressure and pulse rate (if you know)?Anything else I should know?Required *I hereby acknowledge that The Aspen Leaf Spa and has not, is not, and will not prescribe (order for use as medicine) for me at any time, and I will not hold them accountable for such. The colon hydrotherapist is helping me with natural hygiene at my request, and is not diagnosing nor treating disease, nor practicing any form of medicine.I agree to give a 48-hour notice of cancellation or I will be responsible to pay the full session fee or will forfeit a session in any pre-paid package.NameSubmit
