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NATUROPATH MEDICAL LTD

Naturopath Medical Ltd.
240A High Street
Bromley
BR1 1PQ

www.naturopathmedltd.com
moc.dtldemhtaporutanobfsctd-8001d2@ofnI
Mobile/ WhatsApp: 0773 791 5344

Thank you for cooking your treatment with us at Naturopath Medical Ltd. In order to receive the maximum benefit from your treatment or programme please complete this questionnaire and return by email or bring it with you.

Some questions often asked are:
• What can I eat prior to the treatment?
Ans: at whatever time of the day, be it breakfast or other times, you can eat lightly and drink plenty of fluids.
• What can I Wear and Should I bring clothes?
Ans: You can wear loose clothing. You are not required to bring clothes but, if this is your first treatment most people find it less embarrassing, more comfortable and discreet than they ever imagine.
As a qualified Colon Hydrotherapist we are here to guide you toward the safest, most beneficial path for your health goals. Feel free to contact us for personalised advice. If you have any medical conditions, consult your healthcare provider before booking a session.

Firstname

Surname

Date of Birth

Age

Sex

Weight

Mob/Tel:

Have you had colonic before?

Yes No

How did you hear about colon hydrotherapy?

Indicate how long these conditions lasted: (Tick the ones that apply to you or mark with an X)

Over 1 year 2-3 years 5 years or longer

Tell us:

Occupation

Typical Workday if you work

General Eating Pattern:

Please provide more information if other is selected:

Do you smoke?

Yes No

If yes indicate how often

Do you drink?

Yes No

If yes indicate how often

Describe your lifestyle generally, what you really enjoy doing, and what you do to relax?

Are your family members in good health? (This can include your spouse, parents, siblings, children, grandchildren, or grandparents.)

Yes No

Who is the oldest member in your family?

On a scale of 1-10 how would you rate your health, energy & stress right now (1 being the lowest)?

Stress level

Health

Energy

Exercise

The below will be checked

B/P:

Standing B/P:

Do you sleep well & generally how many hours?

Would you like to do anything to alter your health?

When did you last visit the dentist?

Sugar Level:

Describe your typical bowel movements:

When do you generally go to the toilet?

Mid-day Evening Varies Amount

Appearance/ Colour: (if you look, most of us do!):

Haemorrhoids:

Bristol Stool Scale. This is a chart you will be shown during your consultation:

Please add any information on operation/ surgeries in the last 5 years (continue on the next page if needed).

Please list any medications and Natural Supplements you take on daily basis

Please state if you take recreational drugs:

Please tick the following:

I consent to undergo a rectal examination (using non-latex gloves) and to receive Colon Hydrotherapy.* I acknowledge my responsibility to inform my therapist of any changes in my medical condition as indicated in this document. It is especially important to update this information before any future appointments, since new contraindications for treatment may arise.* I understand that any package of Colonic Hydrotherapy treatments I purchase is non-refundable and non-transferable.* I agree to adhere to the scheduled appointment times. If I need to cancel or reschedule, I will provide at least 24 hours’ notice; otherwise, or if I fail to attend, I will be charged the full session fee.* By signing this form I accept the terms and Condition of ’Naturopath Medical Ltd.’ Printed on the Below

Naturopath Medical Ltd. Terms & Conditions
1. All treatments, courses, and packages must be paid in full either at the time of booking or at the conclusion of your first appointment.
2. To reschedule or cancel an appointment, you must provide at least 24 hours’ notice.
3. Cancellations made less than 24 hours before your appointment—or missed appointments—will result in forfeiture of that session (if part of a course or package) or the full session fee being charged.
4. If you arrive late, only the remaining appointment time will be provided. Arrivals more than 20 minutes after the scheduled start time will result in cancellation of the appointment without refund.
I confirm that I have read and agree to the above terms.*
Please sign and date this Questionnaire

Signature

Date

Please respect others time and if you are unable to keep your appointment, for any reason, please give us as much notice as possible. Thank you