Colon Hydrotherapy - KeralaAyurveda

Mobile

Telephone

First Name

Last Name

Postcode

Address

Date of Birth

Email address

Occupation

Please give the following contact details and tick your preferred method of contact

Where did you hear about us?

GP’s Name and Address

Please answer the following as accurately as possible

Are you seeing your Doctor at present? YES NO If Yes, please give details below

Please list any medications and/or supplements you are taking:

Please list any medical conditions you have:

Please list any surgical procedures you have had and the dates:

Please list any allergies you may have:

Do you suffer from any of the following – please tick

Hernia Cancer of the colon or rectum Colitis Congestive heart disease Diverticulitis Fistula

Hirschsprung’s disease High Blood Pressure Ileus (paralytic) Ulcerative Colitis Crohn’s Inflamed haemorrhoids

Rectal bleeding Severe Anaemia Renal insufficiency Severe persistent diarrhoea Controlled high blood pressure Diabetic

Low Blood Pressure Fissure Haemorrhoids Radiotherapy of abdominal area not discharged from medical care

Have you ever had surgery of colon or rectum?

YES NO

If Yes, please state when

Have you ever had a bowel biopsy?

YES NO

If Yes, please state when

Have you a prostate biopsy made through the bowel ?

YES NO

If Yes, please state when

Have you had abdominal surgery e.g. hysterectomy?

YES NO

If Yes, please state when

Have you ever had a recent Laparoscopy?

YES NO

If Yes, please state when

Are you undergoing chemo-therapy and cancer treatments?

YES NO

Do you take oral or rectal steroids?

YES NO

Have you undergone recent (within 6 months) hip/knee joint surgery?

YES NO

Are you pregnant?

YES NO

Are you breastfeeding?

YES NO

Do you smoke?

YES NO

If Yes, please state how many a day

Do you drink alcohol?

YES NO

If Yes, please state how much a week

Do you drink water?

YES NO

If Yes, please state when

Do you have any special diet?

YES NO

If Yes, please describe

General Bowel Movements

Do you require laxatives?

YES NO

If Yes, what do you take?

How would you describe your bowel movements? Please tick where appropriate

Less than once a week Once a day

After eating Occasional

Twice a day Require straining

Every days

Do you suffer from any of the following? Please tick where appropriate

Diarrhoea

Constipation

Gas/Wind

Bloating

Declaration

I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if recommended by my Therapist

Patient Signature

Date

Therapist Signature

Date

Colon Hydrotherapy is a safe and effectively cleanses your large intestine –colon. Your Therapist does not diagnose disease or prescribe medications. Should any of your responses to any of the above questions contraindicate colon hydrotherapy you will be advised to seek your doctor’s help. It is responsibility to provide full and complete answers so your Therapist can treat you correctly. Also you must inform us of any changes to your health between treatments.

General Data Protection Regulations (GDPR)

1. I consent to the data I have given to be used by for the purposes of documenting and communication in regards to the treatment I am undertaking.

2. I understand the data and information on paper copies will be stored securely and any data stored on electronic devices will be password protected.

3. Only information to my treatment will be held and it will be stored for no longer than necessary

4. My data will not be passed to any third party without my consent

5. I am happy to receive any information on promotions and/or newsletter YES NO

6. I consent to being contacted by:

Email YES NO

Tel YES NO

Signed

Date

COVID 19 CHECKLIST

Please answer the following

A. Have you tested positive for COVID-19 in the last 7 days?

YES NO

B Do you have any of the following symptoms?

YES NO

New, continuous cough;

High temperature or fever;

Loss of, or change in, sense of smell or taste?

C Have you been on holiday or outside of UK in the last 14 days?

YES NO

D Have you been to our clinic in the last 4 weeks? If YES, please answer the following.?

YES NO

Is there any change in your health from your last visit to today’s visit? If YES,
please tell us about the change in your health.

YES NO

E Have you been vaccinated? If yes, when did you take the vaccine?

YES NO

Declaration

All the information I have given is accurate and correct and I have not withheld any information about my health. I will keep informed of any changes regarding my health in the future by writing. My Ayurveda Consultant/Therapist has explained the effects and benefits of Ayurveda therapies/Complimentary or beauty therapies and possible effects that may occur as a result, including redness, pain, bruising, some minor reaction, and other contra-indications. I recognize that my participation is voluntary and that I am happy to proceed. I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. If I am not able to make a scheduled appointment, I agree to cancel the appointment by giving 24 hours’ notice before the booked appointment. If I miss a scheduled appointment without giving 24 hours’ notice, I agree to pay for my missed appointment charge.

Patient Signature

Date

OFFICE USE ONLY

F Temperature

YES NO

Kerala Ayurveda Clinic

Colon Hydrotherapy Form

Please give the following contact details and tick your preferred method of contact

Please answer the following as accurately as possible

Do you suffer from any of the following – please tick

General Bowel Movements

How would you describe your bowel movements? Please tick where appropriate

Do you suffer from any of the following? Please tick where appropriate

Declaration

I agree to undergo a possibly rectal examination and subsequent colon hydrotherapy treatment and to receive enema herbs as part of my treatment if recommended by my Therapist

General Data Protection Regulations (GDPR)

COVID 19 CHECKLIST

Please answer the following

Declaration

OFFICE USE ONLY