Client Intake Please enable JavaScript in your browser to complete this form.Today's DateName *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *Date of BirthHeightWeightHow did you learn of our services?Have you ever experienced Colon Hydrotherapy before?YesNoWhen and where?Are you currently under the care of a physician?YesNoPlease state reason and physician's name:Have you ever had abdominal surgery?YesNoPlease explain:If you have had other surgeries, please list them here:Please lit any chronic conditions or illnesses:Please list ALL pharmaceutical medications you use:Please list any OTC medications, vitamins or herbs that you use:Have you ever been on a fast or cleanse?YesNoDid you grow up eating the Standard American Diet?How much water do you drink a day?Do you have regular bowel movements?How many a day?Do you have amalgam (metal) fillings in your teeth?Are there any notable stress factors in your life right now?What are your main wellness goals?Do you suffer from...Abdominal DiscomfortAbdominal HerniaAcid RefluxAllergiesAnemiaAsthmaAutoimmune DisordersBad BreathBile in stoolBlood Pressure (High/Low)Brittle Hair/NailsCandidaCoated TongueCold Hands/FeetConstipationCravingsDark circles under eyesDiarrheaDigestive upsetDiverticulosisExcessive BurpingEczemaFatigueGasGluten IntoleranceHeadachesHemorrhoidsHistory of Intestinal PerforationInsomniaIrritabilityLack of VitalityLow EnergyLymphatic problemsMalabsorptionMenstrual problemsMigrainesOverweight/UnderweightPoor PostureProtruding AbdomenSkin Rashes/DrynessPlease mark all that apply. You may list any other conditions that are not shown here in the field below.Any conditions not listed above:PhoneSubmit
