Please indicate if you have any current problems signs or symptoms.
Please put a (Yes) beside that is currently a problem. Put (No) beside a past problem:
Additional health history for Colon Hydrotherapy
The following are Contraindications for Colon Hydrotherapy.
If any of these apply to you, we are not able to treat you with Colon Hydrotherapy at the present time.
Please check all that is/are currently a problem. Do not check if it is a past problem:
I have never been diagnosed with any contraindications for colon irrigation (see above list). I am aware that Colon Hydrotherapist is not a Physician and therefore does not diagnose or prescribe. I am aware adverse events such as perforation, injury and illness have been alleging and claimed with the use of colon irrigation and enema devices. If during the session I experience discomfort or pain, I am responsible for immediately stopping my session. This facility does not claim or cure or treat any condition or disease.
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(For clients 18 years of age under, the signature attendance of the parents of guardian for insertion is required).
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